Bloodborne Pathogens Exposure Policy

In accordance with the Occupational Safety Health Administration Bloodborne Pathogens standard, 29 CFR 1910.1030, the following exposure control plan has been developed:

Implementation Schedule and Methodology

OSHA requires that this plan also include a schedule and method of implem ntation for the various requirements of the standard. This plan is in effect and will be reviewed on an annual basis.

Compliance Methods

Universal precautions will be observed in order to prevent contact with blood or other potentially infectious material. All blood or OPIM (Other Potentially Infectious Material) will be considered infectious regardless of the perceived status of the source individual. Personal protective equipment shall also be utilized. At the clinical facilities the following engineering controls will be utilized:


Handwashing facilities are also available to students who are exposed to blood or other OPIM.

After removal of personal protective gloves, students shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water or waterless hand cleaner. If students incur exposure to their skin or mucous membranes, those areas shall be washed or flushed with water as appropriate as soon as feasible following contact.

Eye-Wash Station

Following exposure of chemical or body fluid exposure – a 15 minute wash is recommended.


Contaminated needles and other contaminated sharps WILL NOT BE bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required, then the recapping or removal of the needle must be done by the use of mechanical device or a one-handed technique.

Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or OPIM, students are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are located.

Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited. All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or OPIM.

Contaminated Equipment

All garments which are penetrated by blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area.

The following protocol has been provided to facilitate leaving the equipment at the work area:


Gloves will be used for all clinical encounters that present potential contact with blood and body fluids. Gloves will be available in all clinical areas.

Disposable gloves used are not to be washed or decontaminated for re-use and are to be replaced when they become grossly contaminated or torn, punctured, or when their ability to function as a barrier is compromised.


Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or OPIM may be generated and eye, nose, or mouth contamination can reasonably be anticipated. Situations which would require such protection are as follows:

Hepatitis B Vaccine

All students who have been identified as having exposure to blood or OPIM will be offered the Hepatitis B vaccine. The vaccine will be offered within 30 working days of their initial assignment to work involving the potential for occupational exposure to blood or OPIM unless the student has previously had the vaccine or who wishes to submit to antibody testing which shows the employee to have sufficient immunity.

Students who decline the hepatitis B vaccine will sign a waiver which uses the wording in Appendix A of the OSHA standard.

Students who initially decline the vaccine but who later wish to have it may then have the vaccine provided.

Post-Exposure Procedure

ALL exposures need to be reported immediately (within 2 hours) to maximize effective treatment. If indicated, prophylactic medications must be administered within 3 hours.

All students who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. This follow-up will include the following: