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While federal agencies like OSHA and the EPA set the legal minimum standards for laboratory safety, a distinct group of organizations establishes the standard of practice. These entities - ranging from fire protection associations to hospital accreditors - often enforce stricter or more specific safety protocols than the government. For the laboratory manager, compliance with these “voluntary” agencies is effectively mandatory, as failure to do so results in the loss of accreditation, the inability to bill Medicare/Medicaid, and a loss of professional standing

National Fire Protection Association (NFPA)

The NFPA is a nonprofit organization that creates codes and standards to minimize the risk of fire and electrical hazards. While they are a private entity, their codes are adopted by local municipalities (cities and counties), effectively turning them into law

NFPA 704: The “Fire Diamond”

The most visible contribution of the NFPA to the laboratory is the “Standard System for the Identification of the Hazards of Materials for Emergency Response.” This is the diamond-shaped sign often found on laboratory doors or chemical storage cabinets

  • Blue (Health Hazard): Scale 0-4. Indicates the risk to a firefighter upon short-term exposure
  • Red (Flammability Hazard): Scale 0-4. Based on the flashpoint of the chemical
  • Yellow (Instability/Reactivity): Scale 0-4. Indicates susceptibility to explosion or violent reaction
  • White (Special Hazards): Specific symbols like OX (Oxidizer), W (Reacts with water), or SA (Simple Asphyxiant)

NFPA 45: Fire Protection for Laboratories Using Chemicals

This standard dictates specific laboratory design elements, such as:

  • Maximum quantities of flammable liquids allowed per square foot
  • Requirements for fire-rated doors and storage cabinets
  • The mandate that emergency showers be located within 10 seconds of travel time from the hazard

NFPA 101: Life Safety Code

This code governs egress (exits). It ensures that laboratory aisles are wide enough (usually 36 inches) and that exit doors are not blocked by equipment or trash, ensuring safe evacuation during a fire

Clinical & Laboratory Standards Institute (CLSI)

CLSI is a global nonprofit organization that develops voluntary consensus standards. Their documents represent the “Gold Standard” or “Best Practice” for clinical laboratories. While OSHA tells you to have a safety plan, CLSI tells you how to write a comprehensive one

GP17: Clinical Laboratory Safety

This guideline is the foundational document for laboratory safety management. It provides detailed recommendations on:

  • Developing a safety program
  • Implementing engineering controls
  • Designing occupational health programs

M29: Protection of Laboratory Workers from Occupationally Acquired Infections

This specific document expands on the OSHA Bloodborne Pathogens Standard, offering practical, detailed advice on risk assessment for microbiology and virology procedures. It helps labs interpret how to apply Standard Precautions to specific assays

Significance

During legal litigation (e.g., a lawsuit over a lab accident), CLSI standards are often cited as the benchmark for “Standard of Care.” If a laboratory follows OSHA minimums but ignores CLSI best practices, they may still be found negligent

Accrediting Organizations (Deemed Status)

Under the Clinical Laboratory Improvement Amendments (CLIA’88), laboratories must be certified. CLIA allows private organizations with standards “at least as stringent” as federal law to accredit laboratories. This is known as “Deemed Status.” These agencies inspect for both quality and safety

The Joint Commission (TJC)

TJC accredits hospitals and healthcare organizations. Their Environment of Care (EC) standards are rigorous regarding facility safety

  • Focus: TJC places heavy emphasis on the “Environment of Care.” This includes fire safety (drills), utility management (generator testing), hazardous materials management (cradle-to-grave), and security
  • Surveys: TJC surveys are unannounced. Surveyors will trace a patient specimen from collection to disposal, checking safety compliance at every step (e.g., “Is the phlebotomist wearing gloves?” “Is the centrifuge balanced?” “Is the waste bin covered?”)

College of American Pathologists (CAP)

CAP is a peer-review accrediting body specifically for pathology and clinical laboratories. Their Laboratory Accreditation Program (LAP) uses detailed checklists that are discipline-specific

  • The “All Common” Checklist: This checklist contains safety requirements applicable to all sections (e.g., “Are eyewashes checked weekly?” “Is PPE available?”). It is the primary tool for safety auditing
  • Director Responsibility: CAP explicitly holds the Laboratory Director responsible for the safety of the facility. The director must sign off on safety policies annually
  • Specific Checklists: Discipline-specific checklists (e.g., Microbiology, Chemistry) contain focused safety questions (e.g., “Are biological safety cabinets certified annually?” for Micro; “Is waste from the analyzer neutralized?” for Chem)

COLA (Commission on Office Laboratory Accreditation)

COLA primarily accredits smaller, physician office laboratories (POLs) and community hospitals. Their focus is on education and helping smaller labs meet CLIA requirements

  • Approach: COLA emphasizes educational consultation. Their safety standards mirror CLIA/OSHA but are tailored for smaller settings where a full-time Safety Officer may not exist
  • Safety Focus: They verify that the POL has a Chemical Hygiene Plan, that staff are trained, and that MSDS/SDS are available

State & Local Regulations

While not national agencies, local laws often supersede or augment federal regulations. The Safety Officer must be aware of:

  • State OSHA Plans: States like California (Cal/OSHA) and Washington (WISHA) run their own OSHA programs. These state plans are often stricter than federal OSHA. For example, Cal/OSHA has specific standards regarding Aerosol Transmissible Diseases (ATD) that go beyond federal BBP standards
  • Local Fire Marshals: The local fire authority has jurisdiction over building occupancy and fire code enforcement. They can shut down a laboratory immediately if they find blocked exits or significant fire hazards
  • Wastewater Authorities: Local municipal water districts set limits on what can be poured down the drain (e.g., limits on mercury, copper, or pH levels). Laboratories usually require a wastewater discharge permit