This guide will help you get the answers to the CAP safety questions:

Question #	Topic	Answer
57000 58500	competency remediation policy	here is the hospital policy don't print- this is about 50 pages long see pages 11 and 15.
70000	Safety policies	Pathology Safety Manual Hospital Safety Manual * Infection Control Manual* Radiation Safety Manual* *Not in every section- see Administrative office Just-in-time (JIT) on incident reporting
70050	Documentation of accidents	Hospital policy 5040 -see e-copy here
70100	Policies on reporting injuries requiring medical treatment?	Our policy here Safety Manual p 7.1
70150	Are incidents evaluated in the QI process?	Safety Committee reviews all incidents. Policy and procedure is here: Safety Manual p7.3 and QM Operational Plan
70200	Policies on fire prevention	1. Hospital Safety Manual (EOC manual) 2. Our policies 3. Our training module
70250	Fire drills	1. periodic MCL drills 2. one full walk-through drill in annual fire safety meeting (see under activities)
70300	Extinguisher	Part of annual fire safety meeting (under activities)
70350	Electrical policies	1. Yes. See them here. 2. Training module is more comprehensive. 3. Electrical safety checks -JIT(outlets and equip)
70450	Chemical toxin hazard control Chemical hygiene plan	1. General chemical policies 2. Specific policies 3. Training module 4. Chemical storage JIT resource 5. Spill JIT resource Copy of OSHA lab standard
70500	Annual review?	Yes, the entire safety program gets an annual review and written report. Latest report here. Last year's report.
70512	Reduce Mercury	Safety Manual pg 3.3 Email in Safety file to all supervisors
70525	Liquid nitrogen	see thermal safety Safety Manual pg 4.13
70550	Evaluation of carcinogen and reproductive toxicity?	1. The policy is here 2. The coded results are in the chemical inventory program.
70600	Hazardous waste disposal	1. Our site is surveyed by the LA Dept. of Environmental Quality (chemical and biological), and the State Board of Health (biological). 2. Policy 3. JIT on solid wastes. 4. JIT on solvent wastes. Note: Our policies are reviewed by MCL safety and the Office of Infection Control. We have also reviewed the S&WB regulations.
70700	Reducing hazardous wastes	1. see report 2002 2. see report 200 4
70750	Internal and external disasters	1. Hospital policy click here 2. MCL Emergency Preparedness Manual 3. Internal policy 4. JIT for bio disaster for couriers and clerks
70800	Documented evacuation plan- including people with disabilities	1. Evacuation find the evacuation instructions for each site CH and UH. Also find the instructions for those with disabilities.
70816	ergonomic program	see training handout see web index for back training and ergonomics see just-in-time resource Safety Manual pg 5.3
70824	Noise levels	Safety Manual pg 5.4
70832	UV light protection	see the safety manual pg 4.12
70850	Radiation	1. Mostly N/A 2. Radiation safety manual 3. Our RIA policy (find the RIA section) 4. Frances Dunn is our expert on this topic
70900	tissue containing radioactive material	letter from radiation safety officer NA at LSU Interim Hospital
70950	Biohazard control Infection control	1. Our Blood Borne Pathogens plan 2. Our training module 3. Our TB exposure plan 4. JIT on needlesticks 5. JIT on sharps strategies 3. BBP/Needlestick law (click here)
71000	Procurement, transportation and handling of all specimens	1. JIT on outpatient collection 2. JIT on packaging and transportation at MCL 3. JIT on packaging and transportation from outside sites 4. Pre-analytical manual pg 12
71008	blood and body fluid spills	spills are on page 7 Spills in TB lab Spills in the tube system
71016	Effectiveness of engineering controls	1. Annual review of safety program Last review Previous year 2. JIT on sharps strategies 3. JIT on capillary tubes Phlebotomy Training
71032	Glass capillary tubes	.JIT on capillary tubes
71050 71100	Personnel instructed in use of personal protective equipment	Our annual training module: TB exposure and Hepatitis vaccination see the above document Hepatitis C
71200	BBP exposure follow-up	1. MCL protocol on file in Administrative office 2. JIT on injury follow-up 3. BBP/ Needlestick law (click here)
71220	TB exposure plan	Here is our plan
71235	Latex exposure plan	JIT on this topic Training on this topic
71250	Smoking, Drinking, application of cosmetics...?	Our BBP plan Here is workstation description
71300	Recapping, bending needles	Here is our policy
71350	Safety review	We do a quarterly safety committee meeting and twice a year inspection. We do an annual overall review.
71450	Chemical fume hood function verification	Here is the policy- find section on hoods The documentation is on each device
71500	Sterilizing devices	JIT on this topic