Introduction

>Table of Contents

1. Purpose

This Laboratory Safety Plan (LSP) describes policies, procedures, equipment, personal protective equipment and work practices that are capable of protecting employees from the health hazards in laboratories. This Plan is intended to meet the requirements of the federal Laboratory Safety Standard, formally known as "Occupational Exposure to Hazardous Chemicals in Laboratories", a copy of which is found in Appendix A. This LSP also addresses the concerns of the Minnesota Employee Right To Know Act (MERTKA) and the federal Toxic Substance Control Act (TSCA).

This LSP is intended to safely limit laboratory workers' exposure to OSHA- and MERTKA-regulated substances. Laboratory workers must not be exposed to substances in excess of the permissible exposure limits (PEL) specified in OSHA rule 29 CFR 1910, Subpart Z, Toxic and Hazardous Substances. PELs for regulated substances are provided in Appendix B. PELs refer to airborne concentrations of substances that are averaged over an eight-hour day. A few substances (listed under Individual Chemical Standard in the Federal column in Appendix C) also have "action levels". Action levels are air concentrations below the PEL which nevertheless require that certain actions such as medical surveillance and workplace monitoring take place. An employee's workplace exposure to any regulated substance must be monitored if there is reason to believe that the exposure will exceed an action level or a PEL. If exposures to any regulated substance routinely exceed an action level or permissible exposure level there must also be employee medical exposure surveillance.

MERTKA requires employers to evaluate their workplaces for the presence of hazardous substances, harmful physical agents, and infectious agents and to provide training to employees concerning those substances or agents to which employees may be exposed. Written information on agents must be readily accessible to employees or their representatives. Employees have a conditional right to refuse to work if assigned to work in an unsafe or unhealthful manner with a hazardous substance, harmful physical agent or infectious agent. Labeling requirements for containers of hazardous substances and equipment or work areas that generate harmful physical agents are also included in MERTKA.

Toxic Substances Control Act (TSCA) requires that prudent laboratory practices be developed and documented for research involving new chemicals that have not had their health and environmental hazards fully characterized. Laboratories engaged in research must consider the applicability of the Toxic Substances Control Act (TSCA) on their operation. TSCA, administered by the U.S. Environmental Protection Agency (EPA) under the New Chemicals Program [www.epa.gov/oppt/newchems], is intended to ensure that the human health and environmental effects of chemical substances are identified and adequately addressed prior to commercial use or transport of those substances. A new chemical is a chemical substance that is produced or imported and not yet listed on the TSCA Chemical Substance Inventory. Each laboratory or research group that synthesizes or imports new chemicals must determine if and how TSCAapplies to their laboratory activities – see Appendix O.

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2. Scope and Application

The Laboratory Safety Standard applies where 'laboratory use' of hazardous chemicals occurs. Laboratory use of hazardous chemicals means handling or use of such chemicals in which all of the following conditions are met:

1. the handling or use of chemicals occurs on a 'laboratory scale', that is, the work involves containers which can easily and safely be manipulated by one person,
2. multiple chemical procedures or chemical substances are used, and
3. protective laboratory practices and equipment are available and in common use to minimize the potential for employee exposures to hazardous chemicals.

At a minimum, this definition covers employees (including student employees, technicians, supervisors, lead researchers and physicians) who use chemicals in teaching, research and clinical laboratories at the University of Minnesota. Certain non-traditional laboratory settings may be included under this standard at the option of individual departments within the University. Also, it is the policy of the University that laboratory students, while not legally covered under this standard, will be given training commensurate with the level of hazard associated with their laboratory work.

This standard does not apply to laboratories whose function is to produce commercial quantities of material. Also, where the use of hazardous chemicals provides no potential for employee exposure, such as in procedures using chemically impregnated test media and commercially prepared test kits, this standard will not apply. The researchers listed in the following table are covered by this Laboratory Safety Plan.

Principal Investigator	Building	Room #	Primary research hazards
Peter Raynor	Boynton Health Service	S35	Aerosols Chemicals Compressed gases
Lisa Brosseau	Boynton Health Service	S55	Aerosols Chemicals
Matt Simcik, Deborah Swackhamer	Mayo	1135/1140	Chemicals Compressed gases
William Toscano	Mayo	1120	Chemicals Recombinant DNA Biologicals Compressed gas
Elizabeth Wattenberg	Mayo	1120	Recombinant DNA Biologicals Compressed CO2 gas
Heather Nelson	Moos 14-157	14-157	Bloodborne Pathogens Use of Commercially prepackaged test kits
Susan J. Diem, MD Kristine E. Ensrud, MD Aaron R. Folsom, MD Alan T. Hirsh, MD Robert W. Jeffery, PhD Russell V. Luepker, MD Kim Robien, PhD Pamela J. Schreiner, PhD Nancy E. Sherwood, PhD	Epidemiology Clinical Research Center 1100 Washington Avenue South Suite 201 Minneapolis, MN 55415	Lab	Bloodborne Pathogens Use of Commercially prepackaged test kits Use of prepackaged study drug and placebo

3. Coordination With Other Standards and Guidelines

The Laboratory Safety Standard and MERTKA address occupational safety issues. Other federal, state and local standards that address use of hazardous chemicals and other materials are listed in Appendix C. Note particularly the listed chemicals with individual standards in the ‘Federal’ column, since these compounds generally have action limits (usually set at half the TLV), air monitoring requirements, and medical monitoring requirements. If a researcher is using one of these chemicals, or in the unlikely event that there is a conflict between provisions of various standards, the Department of Environmental Health and Safety should be contacted.

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4. Responsibilities

Implementation of the Laboratory Safety Standard at the University is a shared responsibility. Employees, supervisors, Research Safety Officers, department heads, deans, upper administrative staff, and DEHS staff all have roles to play. These roles are outlined below.

A. President, Vice Presidents, Provosts and Chancellors (Central Administration)

University of Minnesota President Robert Bruinicks and Academic Health Center Senior Vice President Frank Cerra are responsible for::

• promoting the importance of safety in all activities;
• promoting the same attitude among all levels of employment at the University;
• supporting a broad-based laboratory safety/chemical hygiene program that will protect U of MN laboratory employees from health effects associated with hazardous chemical, physical or biological agents; and
• ensuring that deans, directors and department heads provide adequate time and recognition for employees who are given laboratory safety responsibilities.

Performance will be measured by:

• DEHS's documentation and annual reporting of the level of compliance within each of the reporting units.

B. Deans, Directors and Department Heads (DDDs)

Dean Finnegan and Division Heads William Toscano (Environmental Health Sciences), Bernard Harlow (Epidemiology and Community Health), John Connet (Biostatistics), and Ira Moscovice (Health Policy and Management) are responsible for:

• identifying at least one technically-qualified research safety officer for the unit. (Colleges or institutes that are made up of a number of large laboratory-based departments are urged to assign research safety officers within each department. Large departments may assign one research safety officer for each division);
• transmitting the name of the designated research safety officer to the U of MN's Chemical Hygiene Officer;
• ensuring that the designated research safety officer is adequately trained regarding the roles and responsibilities of the position;
• ensuring that the designated research safety officer modifies this generic Laboratory Safety Plan to incorporate location-specific information;
• carries out his/her assigned responsibilities
• evaluating the performance of the research safety officer(s) as part of overall job performance; and
• taking appropriate measures to assure that college/department/division activities comply with University and OSHA laboratory safety policies;

Performance will be measured by:

• DEHS's record of a trained, research safety officer for the unit.
• DEHS's record of a current, tailored Laboratory Safety Plan for the unit.

C. Department of Environmental Health and Safety (DEHS)

The Chemical Hygiene Officer for the University is Dawn Errede, and the entire DEHS staff will participate in providing resources for departments in the development of their individual health and safety programs. The Department of Environmental Health and Safety is responsible for:

• preparing and updating the University's generic Laboratory Safety Plan;
• distributing the LSP to departments or other units who will tailor and implement the plan;
• training designated departmental research safety officers regarding their responsibilities for safety and compliance with regulations and University standards that apply to research; and
• monitoring the progress of departments toward achieving compliance.

Performance will be measured by

• DEHS's documentation that review and evaluation of the generic LSP occurs at least annually, updates as necessary;
• annual feedback to DDDs regarding DEHS's records of lab safety officer training and current LSPs within the units;

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D. Research Safety Officer

The RSO’s Roles and Responsibilities are described in greater detail in the RSO Toolkit. Briefly, the RSO will:

• serve as liaison between employing department and the Department of Environmental Health and Safety;
• know the rules, to help researchers comply with applicable state, federal and university requirements;
• develop and implement a Laboratory Safety Plan for the department;
• coordinate training to ensure all researchers understand their responsibilities and the policies that apply to their research.
• coordinate inspections of laboratories and ensure laboratory supervisors address any noted deficiencies;
• keep records to document compliance with state, federal and university requirements.

Performance will be measured by DEHS's documentation that:

• review and evaluation of the tailored LSP occurs at least annually;
• the research safety officer's personal training records are current.

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E. Supervisors/Principal Investigators

The immediate supervisor of a laboratory employee is responsible for:

• assuring that potential hazards of specific projects have been identified and addressed before work is started;
• ensuring there are written, laboratory-specific standard operating procedures for the protocols carried out in the laboratory that incorporate directions about how to mitigate the hazards of the procedures.
• informing and training employees regarding the specific hazards in their area and in the work they will be doing;
• scheduling time for the employee to attend designated training sessions;
• enforcing U of MN safety policies and safe work practices;
• conducting periodic audits of the research space under the supervisors control;
• reporting hazardous conditions to the college or departmental research safety officer;
• investigate laboratory accidents and send an Accident Investigation Worksheet (Appendix N) with recommendations to the departmental research safety officer for review.

Performance will be measured by:

• home department's documentation of current, pertinent safety training for the supervisor and each employee in the supervisor's group;
• home department's documentation of regular audits for laboratory space under the control of the supervisor.

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F. Employee

Employees who have significant responsibility for directing their own laboratory work are responsible for assuring that potential hazards of specific projects have been identified and addressed before work is started. All laboratory employees however, are responsible for:

• attending safety training sessions;
• following safety guidelines applicable to the procedures being carried out;
• assuring that required safety precautions are in place before work is started; and
• reporting hazardous conditions as they are discovered.

Performance will be measured by:

• supervisor's assessment of employee's adherence to topics covered in safety training.