Introduction  

The mission of the Clinical Services of the Laboratory of Pathology (LP), National Cancer Institute (NCI), is to achieve the highest level of quality in diagnostics, education, and research. These goals are supported by a commitment to high standards of laboratory safety. The LP has established a partnership with the clinical and research community at the National Institutes of Health (NIH) to expand the scope of our expertise. This, in turn, will ensure the achievement of our goal to be a globally recognized center of excellence for clinical diagnostics, disease research, and pathology education. This manual is designed to promote the highest standards of safety practices, in keeping with our mission, vision, and departmental philosophy.

This Safety Manual  is organized in an effort to consolidate, condense and streamline the information in our previous manual so that it is easier to find information and ensure that we are covering all regulatory and NIH safety issues for the employees working in the Clinical Services of LP. Annual review and revisions are made to address new safety standards of various regulatory and accrediting bodies and placing the material on the Web for quick and easy access for LP employees.

The contents of this  Safety Manual have been standardized with the exception of variable content (e.g., chemical inventory, Safety Data Sheets, etc.) for all the clinical laboratories and sections and copies are available in each section/unit and office. Note: Each Laboratory Section has a separate Chemical Inventory and Safety Data Sheets (SDS). SDS may also be viewed online using links found at the NIH Safety Data Sheets online .

All employees must review the content of both the Safety Manual and the NIH Clinical Center (CC) Emergency Management Plan (Web and/or printed material) and sign a log indicating they are familiar with its contents. Other very useful Web-based resources include:

The information contained in this manual may be reproduced; however, reference to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government. 

Roles, Responsibilities, and Requirements  

The Medical Director of the Laboratory of Pathology has overall responsibility for ensuring implementation of a safe laboratory environment in compliance with good laboratory practice and applicable regulations. The Medical Director or designee Clinical Manager reviews and approves all new and significant revisions to safety, infection control and environment of care policies and procedures before implementation. However, as a team, All LP employees are responsible for maintaining a safe work environment. This includes knowledge of safe work practices and disposal of all real or potential hazards of wastes. In addition, all employees must use appropriate personal protective equipment and control devices based on the criteria established for their individual sections.

Prevailing local, state, and federal (e.g., OSHA, EPA, etc.) regulations are reviewed by the NIH Division of Occupational Health and Safety (DOHS), Tel: (301) 496-5291. DOHS ensures that methods for disposal of all solid and liquid wastes are in compliance with local, state, and federal regulations and is involved in hazardous waste reduction programs. The Mercury Reduction Program may be viewed at http://orf.od.nih.gov/environmentalprotection/mercuryfree/Pages/NIH-Mercury-Hazard-Reduction-Campaign.aspx and information regarding the Recycling Program may be viewed at http://orf.od.nih.gov/EnvironmentalProtection/WasteDisposal/Pages/recycling.aspx. The DOHS assisted with the preparation of this manual to ensure that the Laboratory of Pathology (LP) is in compliance with regulations.

The Occupational Medical Service (OMS) provides a variety of work-related medical services to the NIH community. Their services include pre-placement medical evaluations, work-related immunizations and laboratory testing, evaluation and care for medical emergencies and occupational injuries, Workers' Compensation support services, a range of Employee Assistance Program services, and CPR training. Although employees should report all work-related injuries and illnesses to OMS, the service is particularly concerned that injuries that could result in potentially life-threatening infections be reported immediately (examples include injuries involving human body fluids). OMS is located in the Clinical Center 6th floor clinic. The clinic is open Monday through Friday from 7:30 am to 5:00 pm and can be reached at (301) 496-4411. OMS health care providers can be reached after clinic hours for potentially life-threatening injuries by calling the NIH Page Operator at (301) 496-1211. If OMS is not available, call 116 for first aid and transportation to Suburban Hospital if necessary. Code Blue is available 24-hours-a-day at 111. 

The Hospital Epidemiology Service (HES) is responsible for the hospital-wide infection prevention program, aimed at preventing nosocomial infections through improved management. This goal includes preventing transmission of infection from patients to patient-care staff or to hospital visitors. The responsibilities of HES include: 1) performing routine surveillance activities to detect the occurrence of nosocomial infections, 2) ensuring that patients with communicable illnesses are placed on appropriate isolation precautions, 3) investigating all potential outbreaks of infection in the NIH Clinical Center, and 4) educating personnel regarding infection control procedures, including Universal Precautions to prevent the transmission of blood-borne pathogens. 

The HES staff is available to all employees to assist in making decisions relevant to the prevention and control of infection in patients as well as personnel. The NIH Clinical Center (CC) isolation policy includes Universal Precautions in the management of blood or body fluids from all patients. Questions about Universal Precautions, about isolation of infected patients, about policies or procedures relevant to infection prevention and/or control, about the management of patients with resistant pathogens or tuberculosis, or any question dealing with the risk of transmitting infection among patients or staff should be directed to this service. Patients or personnel with varicella zoster virus infection, suspected or diagnosed tuberculosis, oxacillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococcus should be reported to the HES as soon as possible. In addition, an Isolation Guidelines guidelines devised by the HES is located at all nursing units and patient care areas as a reference. HES may be contacted by calling (301) 496-2209 or through the signal page operator 496-1211. 

The Division of Occupational Safety and Health maintains surveillance programs of hazardous chemicals (e.g., formaldehyde, xylene, glutaraldehyde). They are responsible for evaluating employee exposure and ensuring compliance with OSHA standards. Call (301) 496-3457 or (301) 496-3353 for more information.

Each Section Head appoints a member from his/her area to serve as a Safety Officer for their area and serve on the LP Safety Committee. The Chief or designate of each section/unit is responsible for additional safety policies and training of employees in the areas of responsibility which are unique to their areas and not specified in this general Safety Manual.

Supervisors will work with committee members to a schedule time and location for specific training requirements for their areas. The supervisors are expected to support the Safety Committee members and allow them to work on safety issues during their normal work day.

The Clinical Manger will Chair the LP Safety Committee. The Chair of the Safety Committee carries out the following responsibilities:

  • Attends and reports safety incidents at the monthly Quality Improvement Committee meetings.
  • Attends Clinical Center Safety Committee meetings.
  • Coordinates chemical exposure monitoring
  • Coordinates environmental assessments and training needs with the NIH Office of Research Services Divisions of Safety and Public Safety.
  • Coordinates LP Safety Committee meetings when appropriate (no less than annually) or disseminates and gathers information via e-mail
  • Works with the LP Chief, the Director of Clinical Service Operations, Section/Unit Chiefs, Technical Laboratory Manager, Supervisors, Hospital Epidemiology, and OMS to ensure CAP, JCAHO and all other regulatory compliance. 

The LP Safety Committee Members and Chair, work together to carry out the following responsibilities:

  • Assist supervisors with safety orientation of new employees.
  • Coordinate evacuation drills (e.g., Fire Drills).
  • Coordinate in-service safety training sessions (e.g., Fire Safety) for LP.
  • Coordinate the function verification of chemical and biological fume hoods and other protective equipment.
  • Function as the Chemical Hygiene Officer for Hazardous Chemicals. Responsibilities include: training employees in the elements of the chemical hygiene plan, documenting that each chemical in the laboratory has been evaluated for carcinogenic potential, reproductive toxicity, and acute toxicity, and verifying that policies are in place which define specific handling requirements of hazardous chemicals
  • Function as the Floor Monitor Warden for evacuation procedures. See NIH Policy Manual #1430 - Occupant Evacuation Plan.
  • Maintain appropriate postings in section.
  • Monitor and document training compliance and notify Section/Unit Chiefs of any delinquencies.
  • Participate in annual review and evaluation of the effectiveness of the LP Chemical Hygiene plan
  • Refer difficult or complex questions to a higher level or a different department (e.g., ORS,  OMS, and HES) based on area of expertise. Working with these departments, the committee will serve as a link to transfer information and assist in trouble shooting problems and concerns and assist with: 1) evaluation of effectiveness of engineering and work practice controls to significantly reduce or eliminate exposure to bloodborne pathogens during laboratory testing, and 2) the selection of products and implementation of work practices that reduce the risk of allergic reactions to job-related exposure of natural rubber latex in gloves and other products.
  • Review and document safe work practices during the Annual Safety Audit and Physical Inspection.
  • Update and maintain Safety Manual and policies.
  • Update Safety Manual as needed in collaboration with the Chief of LP and the NIH Department of Occupational Health and Safety (DOSH). Ensure that copies of revised or new policies are in all manuals and notify Chiefs and Supervisors of changes.

The Program Assistant or Patient Care Coordinator assigned to the Section Head of Clinical Operations is responsible for:

  • Assisting the Safety Committee with monitoring of training compliance.
  • Attending the Safety Committee meetings.
  • Maintaining central files of safety documentation.
  • Performing clerical duties relating to the management of the LP Safety Program. 

At the present time, no known radioactive materials are used in LP for clinical diagnosis. However, potential specimens may be from patients treated with radioactive materials. Employees working near researchers using radioactive materials should be aware that risk from the exposures are minimal, and ensure that radiation safety policies and procedures are being followed. Employees who may receive radioactive specimens must follow specific procedures related to these specimens. 

Radiation Safety Manuals are also available for further reference. In addition, the LP Chief currently serves as the Chair of the Radiation Safety Committee for the entire NIH community. Any questions regarding radiation safety or radioactive specimens should be directed to the ORS-assigned Health Physicist located at https://drs.ors.od.nih.gov/Pages/default.aspx or by calling (301) 496-5574. 

Safe Work Practices Review

The Laboratory of Pathology has periodic review of safe work practices to identify and reduce potential hazards. These reviews include:

  • All safety or infection control issues and occupational injuries are reported to the LP Quality Management Committee monthly to be distributed to all LP staff through committee members. Issues are discussed by QM Committee members to identify potential issues and establish systems, policies or measures to prevent future recurrence. 
  • The NIH Department of Occupational Health and Safety conducts at least annual environmental monitoring: xylene (as requested by each section), formaldehyde, air flow (as requested), and pest management. 
  • The National Cancer Institute (NCI) Safety Committee conducts annual safety and environment of care inspections for all clinical and basic laboratories, corridors and offices in LP. Records of findings and corrective actions are provided to each section head, safety officer and clinical manager.
  • The Clinical Center (CC) Safety Committee conducts at least annual safety and environment of care inspections on all clinical laboratories and administrative areas in accordance with Joint Commission accreditation standards.

Reporting of Safety Concerns or Accidents

Safety concerns may be reported to the Section Head, Section Supervisor, Safety Officer, Chair of the Safety Committee, or the Laboratory of Pathology (LP) Chief at any time. Refer difficult or complex questions to a higher level or different department (e.g., DOHS,  Occupational Medical Services, and Hospital Epidemiology Service) based on area of expertise. All concerns should be forwarded in writing to the Chair of the Safety Committee for review and discussion with the Safety Committee. 

Staff must report laboratory accidents to their immediate supervisor and the Clinical Manager.

Staff must be reffered to Occupational Medical Services for accidents involving harm or potential hazardous or infectious exposure. OMS Guidelines for Medical Emergencies.

Refer to NIH DOHS Spill in Laboratory for guidance on responding to and reporting chemical or biological materials spills.

Annual Mandatory Safety & Environment of Care Training 


Click on Image to Enlarge

1.       One Time / New Employee Orientation:  https://ccrod.cancer.gov/confluence/display/CLPS/Forms+and+Checklists

2.       Safety Manual:  (CCR/OOTC wiki link  https://ccrod.cancer.gov/confluence/display/CLPS/Safety+and+Infection+Control

3.       Lab Safety Training online: (nih training link) https://www.safetytraining.nih.gov/default.aspx?m=Please-Log-In

4.       Blood Borne Pathogens: (nih training link) https://www.safetytraining.nih.gov/default.aspx?m=Please-Log-In#4

5.       Fire Drill Makeup

6.       Universal Precautions Training: http://intranet.cc.nih.gov/hospitalepidemiology/training/index.html

7.       One Time / Ergonomics Training:  http://www.ors.od.nih.gov/sr/dohs/HealthAndSafety/Ergonomics/Pages/ergonomics_home.aspx and LP Training

8.       Infection control:  https://intranet.cc.nih.gov/infectioncontrol/index
Last updated by Lumelski, Victoria (NIH/NCI) [E] on Feb 02, 2024