PALM Safety Handbook Edition Compilation 2

Department of Pathology & Laboratory Medicine, Sultan Ahmad Shah Medical Centre (SASMEC) @IIUM

Laboratory Safety Handbook

For
All Staff of Department of Pathology & Laboratory Medicine, SASMEC @IIUM,

Post Graduate Students, Interns and Researchers

IN CASE OF EMERGENCY, CONTACT:

SASMEC CONTACTS EXTENSION NUMBER
2555
Security Control Room 1232
Emergency Department 2645

PenMedic Counter 3028 / 3021
Housekeeping Department NUMBER

EXTERNAL CONTACTS 09-570 5999

Fire and Rescue Department of Malaysia 09-573 9994
Headquarters, Pahang State
(BOMBA Kuantan)

Indera Mahkota Fire and Rescue Station
(BOMBA Indera Mahkota)

Table of Contents

Content Page
Emergency Escape Route Department of Pathology & Laboratory ii - iii
Medicine (PALM)
PALM Occupational Safety & Health Committee iv
PALM First Aider v
1 Introduction 1
2 First Aid 4
3 Fire Safety 7
4 Chemical Safety 9
5 Biosafety & biosecurity 17
6 Infection Control 20
Appendices 24

i

EMERGENCY ESCAPE ROUTE DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
ii

EMERGENCY ESCAPE ROUTE DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
iii

PALM OCCUPATIONAL, SAFETY AND HEALTH (OSH) COMMITTEE

Chairman Assoc. Prof. Dr. Norlelawati A Talib

Deputy Chairman Asst. Prof. Dr. Norhidayah Kamarudin
Br. Shahriman Ghazali
Liaison Officer to Sr. Siti Norfitrah Mohd Salim
SASMEC @IIUM

Secretary

Chemical Lab Br. Muhammad Nizam Rubani
Management Br. Muhammad Hazim Hamli

Awareness Dr. Norauni Izzati Mohd Asri
Sr. Izyan Syahirah Md Soid
Sr. Fatin Zulaika Ramli
Sr. Norhaffiza Salmi
Sr. Nadzirah Abdul Musawil

Workplace Dr. Syifa Zainal Azhar
Inspection and Br. Mohd Hanif Kasmuri
Safety Incident Br. Muhammad Zikri Sazali
Investigation Br. Muhammad Ikhwan Zurila
Sr. Nurul Hani Izzati Ahmad Zukaidi
Br. Muhammad Alif Shah Awang Ramlan
Sr. Nurul Athira Mohd Salim
All Deputy Technical Managers

Emergency Br. Muhammad Qamarul Izzat Mohd Rodzi
Respond Team Br. Mohd Akrame Mohd Rusli
(ERP) Br. Wan Amirul Afiq Wan Ahmad
Br. Abdul Muqit Abd Waled
Br. Danial Syafiq Daud
Br. Mohd Hanif Nordin

iv

PALM FIRST AIDER

LIST OF FIRST AIDER CONTACT
NUMBER
NO. NAME 010- 538 5725
013- 369 4684
1. DR. SYIFA BT. ZAINAL AZHAR 019- 526 2509
2. DR. WAN MUHAMMAD MUIZZUDDIN B. ZULKIFFLI 017- 377 4462
3. DR. SITI NURHANISAH BT. AZMI 018- 324 3138
4. DR. WAN ALINA KHADIJAH BT. WAN NIK AHMAD MUSTAFA 013- 353 3105
5. DR. SITI ASIYAH BT. SAZALI
6. DR. FATHY NABILA NAJLA BT. M. FUAD

v

SECTION 1: INTRODUCTION

An effective safety and health management system is the key to provide a safe working
environment in the pathology laboratories. Pathology laboratories can be inherently
dangerous places and the attitudes and actions of those who work in the laboratories
determine their own safety, their colleagues and ultimately that of the community. Safety
measures are adopted to reduce these inherent risks in the use of dangerous materials and
potentially dangerous procedures or practices to an acceptable level. However, different
standards are used for different levels of risk and compromises are made so as not to impede
much needed research while keeping risks of those involved to a minimum. Modern pathology
laboratory equipment as well as the design have become more sophisticated and safer, but
safe operation still depends on properly trained personnel, who are safety conscious at all
time. Thus, it is emphasized that proper training and required knowledge of equipment and
materials to be handled must be provided.

The Pathology and Laboratory Medicine (PALM) Department, Sultan Ahmad Shah
(SASMEC) @IIUM provides diagnostic laboratory service beginning August 2016. There are
seven (7) units (laboratories) within the department: Integrated Laboratory; Chemical
Pathology; Haematology; Medical Microbiology; Transfusion; Histopathology & Cytology; and
Medical Genetic. The department also coordinates the management of Specimen Collection
Centre that function as a centre for specimen collection for all clinics and Forensic Unit with
other departments in SASMEC @IIUM.

The Laboratory Management consisting of Head of Department (HOD), Head of Unit
(HOU), Medical Officer (MO), Science Officer (SO), Medical Laboratory Technologist (MLT)
and Medical Health Assistant (MHA) are the key personnel in pathology laboratory. Laboratory
Management staff are experience analytical instrument operators and possess vast
knowledge in various research methodologies. We are committed to provide the highest
quality of laboratory medicine diagnostic services in line with MS ISO 15189 accreditation
requirement. The department aims for MS ISO 15189 accreditation in five years from its
establishment.

1

1.1 LOCATION

Department of Pathology and Laboratory Medicine is located at Level 1 of SASMEC
@IIUM. The address is:

Department of Pathology and Laboratory Medicine,
Level 1, Sultan Ahmad Shah (SASMEC) @IIUM,

Jalan Sultan Ahmad Shah, Bandar Indera Mahkota,
25200, Kuantan,

Pahang Darul Makmur.

The Specimen Collection Centre is located at Ground Floor level of Sultan Ahmad Shah
(SASMEC) @IIUM.

1.2 PURPOSE
The purpose of this handbook is to serve as a general safety guideline to all laboratory users
when dealing with Laboratory Management. This is to ensure meaningful, accurate, and timely
results are obtained after testing, which are required in the management of patients. Contents
of this handbook mainly emphasize on the direction of Laboratory Management through
administration control to reduce the risk elements associate with safety, health and
environment when involving activities related to the laboratory.

Laboratory Management is currently heading towards highest quality of laboratory medicine
diagnostic services which MS ISO 15189 accreditation requirement. The department aims for
MS ISO 15189 accreditation in five years from its establishment. It provides the framework to
allow Laboratory Management to achieve zero incidents, injuries, illnesses, and property
damage. In addition, by following the principles of operating excellence, Laboratory
Management will minimize the potential impact to the environment.

1.3 SCOPE

Laboratory safety rules, regulations, procedures, and existing guideline are applied to all
laboratory personnel, staff, lecturers, students, practical students and any other involve
parties when dealing and utilizing facilities at Department and Laboratory Medicine IIUM
Medical Centre.

2

1.4 IIUM CORPORATE HEALTH, SAFETY AND ENVIRONMENTAL POLICY

The International Islamic University Malaysia (IIUM) strives to achieve excellence in the Health,
Safety and Environmental Management System (HSEMS) at the workplaces by inculcating the
importance of HSE among IIUM staff and members of the public who deal with University.

Thus, the University would like to:
• COMMIT towards compliance with all applicable HSE obligations, legal and other
requirements.
• PROTECT the environment through campus sustainability strategic plan, as well as
prevention of pollution, injury and ill health.
• ENSURE that all premises or workplaces and work systems are safe, not detrimental to
health and conserves the environment.
• PROVIDE basic facilities and equipment in order for the staff to perform their daily
duties safely, in a healthy manner and environmentally friendly.
• ASCERTAIN that IIUM staff be given sufficient information, instruction, training and
supervision on how to work safely without any health or environmental risk to
themselves and others.
• STRIVE for continual improvement in HSENS to enhance performance.

It is abided by the enforcement of legislative requirements as contained in the Law of Malaysia
Act 514 i.e. Occupational Safety and Health Act (OSHA) 1994, its regulations and statutes, all
policies, rules or instructions issued by the IIUM. The policy shall be documented,
implemented, maintained, and communicated to laboratory personnel, staff, lecturers,
students, practical students and any other parties when dealing and utilizing facilities at
Department of Pathology and Laboratory Medicine, Sultan Ahmad Shah (SASMEC) @IIUM.

3

SECTION 2: FIRST AID

A laboratory poses potential hazards due to presence of dangerous chemicals, corrosive
liquids, poisonous chemicals and toxic gases. However, this should not scare anyone as the
dangers can be minimized by adopting laboratory safety measures.

First aid as the name implies is a set of guidelines which can mitigate the damage caused by
exposure to chemicals or injury before expert medical help can be provided. All those in the
laboratory should be familiar with first-aid practices as these save valuable time and reduce
the extent of damage in case of laboratory accidents. Each laboratory should have individuals
who have received the first aid training and have certification from local bodies.

2.1 First Aid Kit

First aid kit should be a dedicated cabinet or box and should contain essential medicines,
antiseptic lotions, creams, bandages and sterilised cotton. A person should be made
responsible for maintaining a list of the contents and discarding the expired medicines and
replacement with fresh stocks. It is a required to inspect the box every 3 months.

PALM first aid kit consists of:

Items Quantity Size
1. Wound bandage 1 1 inch
2. Wound bandage 1 2 inches
3. Triangular bandage with safety pin
4. Splint 2 pack -
5. Crepe bandage 1 box -
6. Crepe bandage 7.5 x 4.5 cm
7. Cotton ball 1 5.0 x 4.5 cm
8. Plaster 1 -
9. Tweezer 2 pack -
10. Surgical tape 5 -
11. Self-adhesive plaster 1 -
12. Latex glove 1 -
1 -
1 pair

4

13. Scissors 1-
14. Antiseptic lotion 1
15. Alcohol swab 4

2.2 Guidelines for First Aid Providers

• Maintain calm and evacuate the area in case there is impending danger.

• Start remedial action to save time before expert medical help can be provided. Do not
attempt to move around the victim unless he / she is exposed to smoke, fire, hazardous
chemicals or vapours. Take proper care in moving to a safe location.

• Ensure that the victim is breathing. If breathing stops try artificial mouth- to- mouth or
mouth- to- nose respiration.

• Do not try to remove deeply embedded metal or glass shreds. Bandage the wounds to
control bleeding till medical help arrives.

• Intense bleeding can be stopped by pressing the wound with your thumb

• In case the victim has fainted turn him/her on the side with the face tilted towards the
floor to prevent choking by the tongue.

2.3 Specific First Aid Tips

Burns – hold the affected skin under a stream of running water for at least 10 – 15 min. Keep
the wound open and do not apply any ointment till expert medical help can be provided. In
case of strong acid burns after washing with water rinse with dilute ammonia (1 – 2%) or sodium
bicarbonate solution.

Caution! never apply acid or alkali to neutralise the corrosive liquid on the skin. Due to heat of
reaction matters can get even more complicated.

Eyes – if corrosive liquid gets splashed into the eyes wash the eyes thoroughly with fresh water
using an eye fountain or eye wash bottle

Poisons – dilute the stomach contents by making the casualty drink 1 – 2 glasses of water and
try to induce vomiting before poison specific expert medical help can be provided.

5

It is a good practice that all employees should be provided first aid training and all should be
familiarized with use of available safety gear. Senior members of the laboratory should hold
periodic safety audits on proper functioning of safety gadgets such as fire extinguishers, safety
showers, eye wash stations and inspect log on replenishment of safety kit contents.

6

SECTION 3: FIRE SAFETY

A fire is an accident that occurs frequently and must be controlled before it spreads and
becomes more dangerous. Laboratory fires may be due to a short circuit, gas explosion, or
highly flammable chemicals. Every member of the PALM community is responsible for knowing
the location of the nearest fire extinguisher, the fire alarm, and the nearest fire escape.
Everyone should be familiar with the use of fire extinguisher.

3.1 Fire Extinguishers
Fire extinguishers are installed throughout campus buildings according to the Fire Services Act
1988. PenMedic is responsible for their maintenance and services. They should be inspected
periodically. All laboratories must be equipped with a fire extinguisher. If an extinguisher is
used assure that it is promptly refilled. For further assistance, please contact the number listed
below.

Kindly refer Fire Extinguisher User Guide in Appendix for reference.

Contact Upon Emergency Contact No.
Fire and Rescue Department of Malaysia 09-570 5999
09-573 9994
Headquarters, Pahang State
Indera Mahkota Fire and Rescue Station Ext. 2645
Ext. 2555
PenMedic Counter, SASMEC @IIUM

Security Control Room

3.2 Fire Blanket

A fire blanket is a highly flame-resistant blanket that can be used to extinguish a small fire or
to wrap around a person in case of a fire. Fire blankets are made from 2 layers of woven glass
fibre fabric and an inner layer of fire-retardant film. They work by cutting off the oxygen supply
to the fire.

Kindly refer Fire Blanket User Guide in Appendix for reference.

3.3 Classification of fires

A fire essentially results from a combination of three entities – combustible material, oxidant
and heat source. All the three are necessary to support and propagate a fire. A fire extinguisher
serves to block the contact of the combustible material with air that supports combustion.

7

Fire Combustible Materials Type of Extinguish Types of Fire
Clarification Material Extinguisher
Wood, paper, Textiles,
A Trash, Plastics, etc. Water ABC
Flammable and
B Foam, Dry Powder, ABC &CO₂
combustible liquids, oil, Carbon dioxide
C gasoline solvents CO₂
Carbon dioxide after de-
D Electrical Fires energizing circuit. Never ABC

Combustible metals: Na, use water
K, Mg, Al Dry powder.
Never use water

3.4 Flammable Laboratory Materials

3.4.1 Flammable and combustible liquids
Flammable liquids are volatile in nature and liberate vapours at ambient or elevated
temperatures that can ignite in presence of sparks, hot plates, naked flames or other hot
surfaces.

Examples: methanol, ethanol, xylene, formalin

Combustible liquids are those whose vapours self-ignite when heated to their flash point
temperature.

3.4.2 Fire Preventive Measures

1. Gas cylinders, gas pipes as well as Bunsen burner tubes must be regularly examined. Soap
solutions must be used for testing gas leakages.

2. Avoid storing large amounts of highly flammable materials in the laboratory. Limit according
to daily requirements only.

3. Laboratory users must plan their work in advance. Most laboratory fires are caused by
negligence and failure to follow the procedures of a given experiment.

4. The switches, connectors, and connection to the electrical equipment must be examined
from time to time to avoid the risk of short circuiting, over-heating or internal arching.

5. Laboratory users must practice hygienic laboratory culture, i.e. tidy the tables and empty the
rubbish bins every day.

6. Laboratory users must be proficient at using fire extinguishers.

7. Make sure laboratory space is free of flammable evaporations. Otherwise, open all the
windows to ventilate the air.

8

SECTION 4: CHEMICAL SAFETY

“La Dharar wa la Dhirar”
There should be neither harming nor reciprocating harm

-By Ibn Majah-

A chemical may be defined as a substance or compound of one or more distinct chemical
elements, whether natural or synthetic. In the laboratory, chemicals has been used in vast
applications including staining kits, reagents, sterilisers and test kits. These chemicals are
mostly hazardous.

Hence, chemical safety guidelines are established to steer employees towards safe
handling of hazardous chemicals. Any chemicals that are contaminated with
microorganisms are excluded from the scope as they are classified under biosafety.

4.1 Common Legal Requirements
Common Legal Requirements Related to Chemicals

Occupational Safety and Health Act 1994
Occupational Safety and Health (Prohibition of Use of Substance) Order, 1999
Occupational Safety and Health (Use and Standards of Exposure of Chemical Hazardous
to Health) Regulation, 2000
Occupational Safety and Health (Classification, Labelling and Safety Data Sheet of
Hazardous Chemicals) Regulations, 2013
Factories and Machinery (Safety, Health and Welfare) Regulations, 1970
Environmental Quality Act 1974
Environmental Quality (Schedule Wastes) Regulations, 2005

9

4.2 Safety Data Sheet

Safety data sheet (SDS) is an information sheet containing safety and hazard
information about a chemical. According to CLASS Regulation 2013, an SDS should be made
available and supplied together with a chemical upon receiving.

An SDS should be updated within 5 years since the last date of preparation/revision and
shall contain these information:

• Identification of the hazardous chemical and the supplier.
• Hazard identification.
• Composition and information of the ingredients of the

hazardous chemical.
• First-aid measures.
• Fire-fighting measures.
• Accidental release measures.
• Handling and storage.
• Exposure controls and personal protection.
• Physical and chemical properties.
• Stability and reactivity.
• Toxicological information.
• Ecological information.
• Disposal information.
• Transportation information.
• Regulatory information.
• Other information

10

4.3 Pictogram
There are nine (9) pictograms according to Global Harmonized System of Classification
and Labelling of Chemicals (GHS):

4.4 Chemical Registry
According to USECCH Regulation 2000, a register of hazardous chemicals must be
established where the hazardous chemicals are found. This register must be regularly
maintained and be updated if needed.

4.5 Risk Assessment
Control measures must be taken before every work involving hazardous chemicals is
carried out to reduce the risk. Therefore, it should be preceded by a risk assessment
according to USECCH Regulation 2000. This register needs to be maintained and updated.
11

4.6 Chemical Handling

• Chemical users should be responsible for any activities involving the use of chemicals.
• Safety Data Sheet (SDS) should be made available and utterly understood before

handling a chemical.
• Precaution should be given according to the pictogram and hazard statement of a

chemical during utilisation.
• Do not inhale or taste any chemical for discerning.
• Hazardous chemicals should be operated in a fumehood properly.
• A proper Personal Protective Equipment (PPE) should be worn during the handling of

a chemical.
• Good housekeeping should be practiced after chemical utilisation.
• Use the designated trolley when transporting a large container of chemical (eg:

Winchester Bottle).
• All chemical containers should come with labels and aliquoted containers should be

relabelled according to CLASS Regulation 2013.

4.7 Chemical Storage

1. Safety Data Sheet (SDS) should be made available and utterly understood before
storing a chemical.

2. Chemicals should be stored accordingly in a proper place as determined from Risk
Assessment.

3. Hazardous chemicals should be stored below than eye level.
4. Chemicals should be stored according to the compatibility between different

chemicals (refer to Figure 1).

12

Figure 1: Chemical storage compatibility

4.8 Chemical Disposal
• All chemical disposal process must adhere to the Environment Quality Act 1974.
• It is the responsibility of waste generator to properly identify, segregate, pack, label
and store all hazardous chemical for disposal as required by Environmental Quality
(Scheduled Wastes) Regulations, 2005.
• Identification of waste can be made either by referring to its original SDS or based on
process knowledge or history.
• Flow of chemical waste from waste generator to temporary are as below:

13

Workflow Work details Responsibility

Collecting 1. Wear right personal protective equipment Medical
chemical waste at (PPE) Laboratory
respective 2. Never leave chemical waste unattended. Technologist
laboratory unit 3. Pour chemical waste into suitable waste
bottle
4. Label waste bottle with chemical waste
label customized by each unit; refer Figure 2
5. Store waste bottle at suitable place

Repository in 1. Keep full bottle of chemical waste in an Medical
particular unit. appropriate place Laboratory
2. Make sure the bottle must not very full and Technologist
capped tightly to avoid leakage or vapour
leaking.

Delivery of 1. Wear right personal protective equipment Medical
chemical waste to (PPE) Laboratory
the storage room 2. Record total number of waste bottle is Technologist
collected. Update waste inventory.
3. Transport chemical waste bottle using
designated trolley.
4. Send the chemical waste to the chemical
storage room using waste route (Laluan
Bahan Buangan).
5. Place the waste bottle accordingly to type
of chemical.

Disposal of 1. All chemical waste bottle is transported to Appointed
Chemical Waste the disposal factory and will dispose vendor of
accordingly. SASMEC @IIUM

• All waste container must be labelled and must be complied to regulation 10 of
Environmental Quality (Schedule Wastes) Regulation 2005.

• Guidelines on how to label a chemical waste as shown in Figure 2.

14

Relevant pictogram

10 cm 45ᵒ

Type of chemical Write the name of
and code chemical waste upon
discarding
Write the date of
waste collection Name of Unit, Ext No.

Figure 2: Specifying a chemical waste label.

4.9 Chemical Spillage

4.9.1 Chemical spills can be classified as ‘minor spill’ or ‘major spill’ as such:
Minor spill : Where the chemical spill is approximately less than 1 litre with low
potential of immediate risk to health.
Major spill : Where the chemical spill is more than 1 litre with high potential of fire and
explosion or might cause acute health hazard.

4.9.2 In any cases of spill, the following steps (Figure 3) can be applied :

15

Spill occur
Warn others

Persons Yes First aider? No
injured?

No Yes
Yes Give first aid treatment
Person contaminated with
spill

No

Risk
assessment

Major Spill Minor spill
Isolate spillage area
Clean-up the spill using appropriate
PPE and Chemical Spillage Kit

Inform area incident officer
Figure 3: Chemical spillage flow of process.

16

SECTION 5: BIOSAFETY & BIOSECURITY
Biosafety is defined as the containment conditions under which infectious agents can be safely
manipulated. The purpose is to protect laboratory user from biological hazard.
Biosecurity is related to protection, control and accountability measuring implementation of
valuable biological materials (biological agents, toxins and related resources) within
laboratories. The purposes are to prevent the loss, theft, misuse, diversion or intentional
release.
Biological hazards or biohazard defined as biological substance that poses a threat to the
health of living organisms, primarily humans i.e. bacteria, virus, parasite, fungi or toxin (from a
biological source) that can affect human health, animal and the environment.
Laboratory facilities are designated as Biosafety Level 1 (basic), Biosafety Level 2 (basic),
Biosafety Level 3 (containment), Biosafety Level 4 (maximum containment). Biosafety level
designations are based on a composite of the design features, construction, containment
facilities, equipment, practices and operational procedures required for working with agents
from the various risk groups.
Biosafety level in PALM laboratories generally are BSL 1 and BSL 2. Modified BSL 2 is to
accommodate current available facility.

17

PALM Biosafety Level

BSL Type Type of Procedure Name of Classification of Risk Group Work Station / Safety
1 (Basic) Microorganism Infective 1 Current Lab Equipment
1 (Basic) Lab testing, blood group (example) Microorganism Practice
1 (Basic) crossmatching - - Lab bench PPE Level 1
2 (Basic) Slide staining, sample sorting -
Inoculating bacteria, staining - Bacteria 1 Lab bench PPE Level 1
2 (Basic) Bacillus spp., 1 Lab bench PPE Level 1
Lab testing, blood group except B. cereus Coronavirus
Modified crossmatching, slide staining, and B. anthracis 2 BSC II PPE Level 2
BSL 2 sample sorting of Covid-19 PUI - Bacteria,
samples Chlamydia, 2 BSC II PPE Level 2
Making smear form Gram Helicobacter Mycoplasma
staining (BSC type II), Staining pylori, Bacillus 3 BSC II, negative PPE Level 2
(Over sink at Staining area), cereus, Bacteria, pressure isolated
Observing using light microscope Staphylococcus Chlamydia, room
on benchtop inside the aureus, Rickettsia
bacteriology lab room, Culturing Streptococcus
using aseptic technique pneumonia
(benchtop), Making suspension
from growth for identification Mycobacterium
and antimicrobial sensitivity test. tuberculosis
Making AFB smear (BSC type II), (multi-drug
Staining (Fume Hood), Observing resistant strains)
using fluorescent microscope

18

3.5 Biosafety management
1. It is the responsibility of the laboratory director (the person who has immediate
responsibility for the laboratory) to ensure the development and adaption of a biosafety
management plan and a safety or operations manual.
2. The laboratory supervisor (reporting to the laboratory director) should ensure that regular
training in the laboratory safety is provided.
3. Personnel should be advised of special hazards, and required to read the safety or operation
manual and follow standard practices and procedures. The laboratory supervisor should make
sure that all personnel understand these. A copy of the safety or operations manual should be
available in the laboratory.
4. There should be an arthropod and rodent control programme.
5. Appropriate medical evaluations, surveillance and treatment should be provided for all
personnel in the case of need, and adequate medical records should be maintained.

19

SECTION 6: INFECTION CONTROL

References are made to the relative hazards of infective microorganisms by risk group (WHO
Risk Groups 1, 2, 3 and 4). This risk group classification is to be used for laboratory work only.
Table 1 describes the risk groups.

Table 1: Classification of infective microorganisms by risk group

Group Risk Type of infective organism
1 no or low individual and A microorganism that is unlikely to cause human or
2 community risk animal disease.
moderate individual risk, low A pathogen that can cause human or animal
3 community risk disease but is unlikely to be a serious hazard to
4 laboratory workers, the community, livestock or
high individual risk, low the environment. Laboratory exposures may cause
community risk serious infection, but effective treatment and
preventive measures are available and the risk of
high individual and community spread of infection is limited.
risk A pathogen that usually causes serious human or
animal disease but does not ordinarily spread from
one infected individual to another. Effective
treatment and preventive measures are available
A pathogen that usually causes serious human or
animal disease and that can be readily transmitted
from one individual to another, directly or
indirectly. Effective treatment and preventive
measures are not usually available.

6.1 Guidance and Recommendations
Diagnostic and health-care laboratories (public health, clinical or hospital-based) must all be
designed for Biosafety Level 2 or above. As no laboratory has complete control over the
specimen it receives, laboratory workers may be exposed to “high risk group” organisms.

20

Therefore, standard precautions should always be adopted and practiced, as well as to
promote good (i.e. safe) microbiological techniques (GMT).

6.2 Code of Practice
This code is a listing of the most essential laboratory practices and procedures that are basic
to GMT. Each laboratory should adopt a safety or operation manual that identifies known and
potential hazards, and specifies practices and procedures to eliminate or minimize such
hazards. The most important concepts are listed below.

6.2.1 Access
i) The international biohazard warning symbol and sign must be displayed on the
doors of the rooms where microorganisms of Risk Group 2 or higher risk groups
are handled. (Table 1)
ii) Only authorized persons should be allowed to enter the laboratory working areas.
iii) Laboratory doors should be kept closed.
iv) Children should not be authorized or allowed to enter laboratory working areas.

6.2.2 Personal protection
i) Laboratory coveralls, gowns or uniforms must be worn at all times. The
coat/gown should be removed before leaving the laboratory and placed on the
area provided.
ii) Appropriate gloves must be worn for all procedures that may involve director
accidental contact with blood, body fluids and other potentially infectious
materials. After use, gloves should be removed aseptically and hands must then
be washed.
iii) Personnel must wash their hands after handling infectious materials and before
leaving the laboratory working areas.
iv) Protective devices must be worn whenever necessary to protect the eyes and
face from splashes, impacting objects and sources of artificial ultraviolet
radiation.
v) Any cuts, abrasions or other skin lesions must be properly covered to protect
them against contamination before starting work.

21

vi) Eating, drinking, smoking, applying cosmetics and handling contact lenses is
prohibited in the laboratory working areas.

vii) Storing human foods or drinks anywhere in the laboratory working areas is
prohibited.

6.2.3 Procedures
i) Materials must not be placed in the mouth.
ii) Any technical procedures should be performed in a way that minimizes the
formation of aerosols and droplets.
iii) The use of hypodermic needles and syringes should be limited. They must not be
used as substitutes for pipetting devices.
iv) All spills, accidents and overt or potential exposures to infectious materials must
be reported to the laboratory supervisor. A written record of such accidents and
incidents should be maintained.
v) A written procedure for the clean-up of all spills must be developed and followed.
vi) Contaminated liquids must be decontaminated (chemically or physically) before
discharge to the sanitary sewer. An effluent treatment system may be required,
depending on the risk assessment for the agent(s) being handled.
vii) Written documents that are expected to be removed from the laboratory need to
be protected from contamination while in the laboratory.

6.2.4 Laboratory working areas
i) The laboratory should be kept neat, clean and free of materials that are not
pertinent to the work.
ii) Work surfaces must be decontaminated after any spill of potentially dangerous
material. At the end of the working day all working surfaces must be
decontaminated.
iii) All contaminated materials, specimens and cultures must be decontaminated
before disposal. Decontamination shall be done for any reusable materials
iv) Packing and transportation must follow applicable national and/or international
regulations.

6.2.5 Health and Medical Surveillance

22

The employing authority, through the laboratory director, is responsible for ensuring that
there is adequate surveillance of the health of laboratory personnel. The objective of such
surveillance is to monitor for occupationally acquired diseases. Appropriate activities to
achieve these objectives are:

i) Provision of active or passive immunization where indicated
ii) Facilitation of the early detection of laboratory-acquired infections.
iii) Exclusion of highly susceptible individuals (e.g. pregnant woman or immuno-

compromised individuals) from highly hazardous laboratory work.
iv) Provision of effective personal protective equipment and procedures.

Guidelines for the surveillance of laboratory workers handling microorganism at Biosafety
Level 2

i) A pre-employment or pre-placement health check is necessary. The person’s
medical history should be recorded and a targeted occupational health
assessment performed.

ii) Records of illness and absence should be kept by the laboratory management

6.2.6 Waste Disposal and Decontamination

Identification and separation system for infectious materials and their containers should be
adopted. Categories should include:

i) Non-contaminated (non infectious) wastes can be reused or recycled or disposed
of as general, “household”.

ii) Contaminated (infectious) “sharps” – hypodermic needles, scalpels, knives and
broken glass. These should always be collected in puncture-proof containers fitted
with covers and treated as infectious.

iii) Contaminated material for decontamination by autoclaving and thereafter
washing and reuse or recycling.

iv) Contaminated material for autoclaving and disposal.
v) Contaminated material for direct incineration.

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APPENDICES
1. Fire Extinguisher User Guide
2. Fire Blanket User Guide
3. Scheduled waste labelling (Type of Chemical Waste)
4. Infection Control Checklist
5. Forms

i) Incident Notification Form

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Fire Extinguisher User Guide
25

Fire Blanket User Guide
26

TEMPORARYType of Chemical Waste
STORAGE FOR

CHEMICAL
WASTE

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No. Type of Label Type of Chemical Waste
Label Type of Waste

SOLID WASTE

1 Toxic Substances, SW 409 Disposed Container, Bags or
Equipment contaminated with
Scheduled waste

LIQUID WASTE

2 Toxic Substances, SW 320 Any waste containing Formaldehyde
10% NBF waste
Decalcifier waste

3 Toxic Substances, IHC waste
Corrosive Substances, SW 322 Wash Solution waste

Inflammable Liquids, SW 322 Alcohol waste
4 Haematoxylin waste
Xylene Waste
Mounting medium waste

5 Toxic Substances, SW 322 Methanol waste

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6 Inflammable Liquids, SW 323 Eosin Waste
Combine dyes Special stain waste
Methylene blue waste

7 Toxic Substances, SW 323 Trace Metals:
(Sodium bisulfite 1%, Perchloric Acid
10%) waste

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INFECTION PREVENTION & CONTROL ORIENTATION CHECKLIST
IIUM MEDICAL CENTRE

NAME :
POSITION :
I/C NO/STAFF NO :
DATE :
DEPARTMENT/ WARD :

ORIENTATION OBJECTIVES :
1) To educate on the importance of standard precautions
2) To educate on transmission-based precautions (Contact, Droplet, Airborne)
3) Prevent tranmission of healthcare-associated infection (HCAI)
4) Prevent incidence of sharps injury

NO ACTIVITY ACTION REMARKS
1 HAND HYGIENE NO

YES

Alcohol handrub - 7 steps (20-30 sec)

Pour enough hand sanitizer onto your left palm.
Dip all fingers of the right hand onto the left palm, followed by dipping left fingers onto the right palm.
Rub hands palm to palm.
Right palm over left dorsum with interlaced fingers & vice versa
Palm to palm with fingers interlaced
Backs of fingers to opposing palms with fingers interlocked
Rotational rubbing of left thumb clasped in right palm & vice versa
Rotational rubbing of right wrist clasped in left palm & vice versa
Handwash- 7 steps (40-60sec)

i. Pour enough soap onto your left palm.
ii. Rub hands palm to palm.
iii. Right palm over left dorsum with interlaced fingers & vice versa
iv. Palm to palm with fingers interlaced
v. Backs of fingers to opposing palms with fingers interlocked
vi. Rotational rubbing of left thumb clasped in right palm and vice versa
vii. Rotational rubbing of left thumb clasped in right palm & vice versa
viii. Rotational rubbing of right wrist clasped in left palm & vice versa

5 moments of hand hygiene :

Before patient contact
Before aseptic task
After body fluids exposure risk
After patient contact
After contact with patient surroundings

PERSONAL PROCTECTIVE EQUIPMENT

2.1 Mask

# Surgical mask (for contact & droplet precaution) / N95 mask (for airborne precaution)

Must cover nose and mouth
Do fit check for N95 mask
Proper removal of mask
Avoid hang mask under chin
Do not keep mask in the pocket
Change if wet or stained
2.2 Glove

2 types of glove: sterile & non-sterile

Gloves should not be regarded as a substitute for hand hygiene
Should not be recycled
Should be changed in between patients or procedures ( Do not perform handrub on top of the gloves )
Contamination may occur upon gloves removal
Wash hands before and after wearing
Remove it immediately after use
Dispose off into clinical waste bin

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NO ACTIVITY YES NO REMARKS
2.3 Goggle / face shield/ head cover/ hijab cover
For contact & droplet precaution
a) Goggle/ face shield: should cover eyes / face
b) Head cover: should cover hair
c) Hijab cover: should cover neck, ears, hair

2.4 Apron / gown
Fundamental basis for universal precaution (covers contact, droplet & airborne precaution)
a) Waterproof
b) Long sleeves to celebrate birth and upon performing aerosol-generating procedure
c) Must be change in between patient
d) Doff in a correct way
e) Wash hand after doff the gown
f) Disposed off into the clinical waste bin

2.5 Rubber boots
Used when doing procedure that involve the possibility of excessive blood and fluid spills

2.6 Shoes cover
Used when treating patient in isolation room / in units of sterility control need to be obey
Examples : CSSD, Burn Unit

LEVEL 1
PPE MATERIAL
Plastic apron
Gloves
Surgical mask/ goggle/ full face visor
SITUATION : No suspected or known infectious agent.
Anticipated exposure to blood and/or other body fluids.
LEVEL 2 (Contact)
PPE MATERIAL
Plastic apron
Full body gown
Gloves
Surgical mask/ goggle/ full face visor
SITUATION : Suspected or confirmed infectious agent spread by DIRECT/INDIRECT CONTACT e.g.
ESBL, MDRO, MRSA. Anticipated exposure to blood and/or other body fluids
LEVEL 2 (Droplet)
PPE material
Plastic apron
Full body gown
Gloves
Surgical mask/ goggle/ full face visor
SITUATION : Suspected or confirmed infectious agent spread by the DROPLET route e.g. respiratory
viruses
LEVEL 2 (Airborne)
PPE material
Plastic apron
Full body gown
Double gloves
N95/ goggle/ full face visor or powered hood respirator
Head cover
Boots
Boot/ shoes covers
SITUATION : Suspected or confirmed infectious agent spread by the AIRBORNE route e.g.
Chickenpox, Pulmonary TB, Measles
Aerosol-generating procedures
LEVEL 3

PPE MATERIAL

Plastic apron

Jumpsuit

Hood & mask

Goggle

Double gloves

Boots

Boots cover

SITUATION :For suspected or confirmed Infectious Diseases of High Consequence. Spread by
DIRECT/INDIRECT CONTACT e.g. Ebola virus, Lassa virus

Spread by the AIRBORNE route e.g. SARS, MERS-CoV, Avian Influenza

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3 SOCIAL DISTANCING

a) To stay home & notify workplace administrators when sick
b) If symptomatic at work, avoid contact with fellow employees and inform employers (for
screening/ home surveillance)
c) for telework when feasible (in between department, interstate, interorganization, when staff
under home surveillance)
d) No handshake policy
e) Increase physical space between staff (1 metre apart)
f) Limit in-person meetings. If unavoidable, meeting should be short.
g) To take meals at their desk
h) Avoid congregating at workspace & pantry
i) Avoid large work-related gatherings (e.g., staff meetings, after-workfunctions).
j) Avoid non-essential work travel.

4 WASTE MANAGEMENT
Domestic waste - in black plastic/ bin
a) Used tissue and paper
b) Food waste from non infected patient
c) Material not contaminated by body fluid

Clinical waste -in yellow plastic/ bin
a) PPE materials e.g. glove / gown / apron / cap / mask
b) Dressing / gauze / swab
c) Contaminated material by blood / body fluids
d) All syringes without needles discarded into clinical waste bin
# Make sure the waste does not spilled out

Sharp tools - in sharp bin
a) Needle / syringe / glass / ampoule
b) Blade / razor / wood (spatula or orange stick) broken
c) Trocar: disposed into trocar bin
*Do not throw syringes into the trocar bin
d) Disposal of chemo - disposed of to a special sharp bin label with chemo
e) Vial
f) Expired, unused and contaminated drugs and vaccines
# Use forcep to pick up the fallen needle
# Sharps containers when filled to the fill line (¾ full) shall be sealed to prevent
further filling of sharps.
# Placed in the safe area

NO ACTIVITY YES NO REMARKS
5 LINEN MANAGEMENT

White Linen Bag
For all normal soiled and foul linen

Red Linen Bag
For infected linen to be lined with Red Alginate Plastics

Green Linen Bag
For all Operation Theatre / CSSD linen

Brown Linen Bag
For reject linen

In performing this procedure, HCWs must don appropriate PPE (apron, mask and gloves) and
perform hand hygiene before and after the procedure.
a) To segregate and remove any foreign items before placing soiled linen in the appropriate colour
coded bags.
b) To tie the soiled linen bag when it is ¾ full and replace with another bag
c) To place soiled linen bags neatly on the racks at the Used Soiled Linen Area.
d) To place contaminated linen directly into a laundry bag in the isolation room/ area with minimal
manipulation to avoid contamination of air, surfaces andperson

* Do not put dirty linen on the floor
*Avoid placing the linen on the lid of the beg
*Make sure bag is always closed

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6 DISINFECTION AND STERILIZATION

*Sterilization is the elimination of all disease-producing microorganisms, including spores.
* Disinfection is the inactivation of disease-producing microorganisms. Disinfection does not destroy
bacterial spores or prions.
* To ensure appliances that require soaking with disinfection solution to be totally submerged into
the solution.
* Use appropriate disinfectants and follow the manufacturer's instructions

STORAGE OF CSSD SET
a) Sterile storage should only be used to store sterile items.

b) Sterile items/ equipment should be stored and handled in a manner that maintain the integrity of
packs and prevent contamination from any source (Only one person should be incharge)
c) The storage area should be clean and free from dust, insects and vermin.
d) Storage, carts and shelves should not be overloaded.
e) The sterile items should be arranged according to the size (big sets singly, and small set not more
than 3 stacks)
f) ‘First in, first out’ (FIFO) is the principle to follow in the removal and replacement of sterile items
in sterile storage.
g) The shelf life of a packaged sterile item is event-related (no expiry date).

h) Damaged sterile set (holes/ tears, wet package) should not be used & should be return to CSSD.

i) Routine checking of storage area is necessary on a regular basis and should be documented.

Note: Hand hygiene should be performed before accessing clean/ sterile supplies. Do not use
gloves.

NO ACTIVITY YES NO REMARKS

7 ENVIRONMENTAL HYGIENE
a) Cleaning need to been done according to the schedule
b) Use of mop according to the criteria set
e.g.
Red mop- Toilets, Dirty Utility, Sluice Room
Blue mop -Medical Areas / Clinics
Green mop - Specialized area ( Opeartion Theatre / milk room / ICU / Lab / Pharmacy / Isolation
Wards or Rooms ) and spillages
Yellow mop- General Areas (Non-Clinical Areas)
White mop- polishing

c) All medical equipment must be free from dust
d) Blood and body fluid spillage should be clean immediately.

Spillage Management
a) Clean immediately
b) Select appropriate PPE
c) Small spills (up to 10cm diameter) - Remove with absorbent material, wipe with Sodium
hypochlorite 1:10
d) Large spills (greater than 10cm diameter)- Cover spillage with absorbent material, pour Sodium
hypochlorite 1:10 and leave for 5-10 min.
e) or use " Spillage Kit" - Sprinkle chloride granules leave for 5-10 min.
f) Scoop with brush and dust pan and discard into clinical waste bin
g) Mop the area with Sodium hypochlorite 1:100.

8 RESPIRATORY HYGIENE & COUGH ETIQUETTE
All individuals (HCWs, patients and visitors) with signs and symptoms of a respiratory infection
should :
a) Cover their mouth and nose when coughing/sneezing;

b) Use tissues, handkerchiefs, cloth masks or medical masks if available, as source control to contain
respiratory secretions, and dispose of them into the clinical waste bins
c) Use a medical mask on a coughing/sneezing person when tolerated and appropriate; and perform
hand hygiene
d) Ensure sosial distancing of 3 feet (1 meter)

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NO ACTIVITY YES NO REMARKS

9 INCIDENCE OF SHARP INJURY

If the skin is broken following an injury:
· Do not squeeze or rub the injured site.

· Wash the site immediately using soap or mild disinfectant solution that will not
irritate the skin. (WHO recommends the use of a chlorhexidine gluconate solution).

· If running water is not available, clean the site with gel or other hand-cleaning
solution, whatever is customarily available.
· Do not use strong solutions, such as bleach or iodine to clean the site as these may
irritate the wound and make the injury worse.

After a splash of blood or body fluids:
· Wash the area immediately.
· If running water is not available, clean the area with gel or other hand rub
solution, whatever s customarily available
· Do not use strong disinfectants.

After a splash contacts the eye:
· Do not use soap or disinfectant on the eye.
· Irrigate the exposed eye immediately with water
· Sit in a chair, tilt the head back and have a colleague gently pour water or normal
saline over the eye, pulling the eyelids up and down to make sure the eye is cleaned
thoroughly.
· If contact lenses are worn, leave these in place while irrigating the eye, as they
form a barrier over the eye and will help protect it.
· Once the eye has been cleaned, remove the contact lenses and clean them in the
normal manner. This will make them safe to wear again.

After a splash contacts the mouth:
· Spit the fluid out immediately
· Rinse the mouth thoroughly using water and spit again.

* Inform Site Supervisor
* Inform Coordinator Infection Control
* If source is known,for staff to take the source blood & send for HIV Ag/Ab, antiHCV and HBsAg
test
* Go to emergency department for further management

NO ACTIVITY YES NO REMARKS

10 IMMUNIZATION

IMMUNIZATION HEPATITIS B
a) Hepatitis B antibody screening, if ever take immunization
b) Injection of Hepatitis B (3 dose) if antibody non-reactive. If antibody <10mlU/L, booster dose may
be required.

* Antibody screening should be done after 2 months after receive the third dose

11 TRANSPORTATION OF SPECIMEN
a) Forms and specimen should be labelled with patient 's name and RN
b) The specimen is in the correct container and closed neatly
c) Specimens are placed in 'Biohazard' plastic bags

Signature of staff ; Signature of Infection Control
Team;

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Source: KKM Infection Control Guidelines
References:

1. Department of Biosafety under the Ministry of Natural Resources and Environment
2. IIUM Biosafety Guidelines, Institutional Biosafety and Biosecurity (IBBC) of

International Islamic University Malaysia
3. KKM Infection Control Guidelines

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