Hospitals: Solutions to Common Safety and Health Violations

Several divisions within the Department of Labor & Industries perform surveys, audits, examinations or inspections in hospitals. Each has compiled a list of most frequent problems identified in hospital, and how hospitals may avoid or address the problems.

For most questions related to DOSH and hospitals, please contact a DOSH safety and health consultant.

The following items represent common problems found during L&I inspections and audits in hospitals, and how to address them.

Problem Remedy
A written Accident Prevetion Program (APP) has not been developed Develop and maintain a written Accident Prevention Program as required by WAC 296-800-140.
The Accident Prevention Program did not include a section on workplace violence prevention. Implement a plan to reasonably protect employees from violence as required by RCW 49.19 and WRD 5.07 Workplace Violence Prevention in Healthcare.
A safety committee with employee-elected and employer-selected members is not in place Institute a safety committee and conduct safety meetings as required under WAC 296-800-130. Make sure the number of employee-elected members equals or exceeds the number of employer-selected members.
A written Chemical Hazard Communication Program has not been developed Develop and make avalable a written Chemical Hazard Communication Program as required under WAC 296-800-170. Sample Hazardous Chemical Communication Program.
The bloodborne pathogens Exposure Control Plan (ECP) is incomplete Make sure that ECP includes all of the elements listed in WAC 296-823-1105. Sample ECP.
Employees are not receiving effective safety orientation training. Make sure that workplace hazards are identified in your APP or department policies. Employees must receive training prior to job duty assignment and whenever exposures or processes change, WAC 206-800-140.
Employees are not using appropriate personal protective equipment (PPE) Conduct a PPE Hazard Assessment and provide appropriate PPE as required under WAC 296-800-160. Require your employees to use necessary PPE. Personal Protective Equipment Guide.
Appropriate emergency washing facilities are not provided in areas where employees mix hazardous chemicals Identify areas where chemical usage requires an emergency shower and/or eyewash facility to be and make sure appropriate emergency washing is provided under WAC 296-800-15030 through –15040.
Where there is potential exposure to asbestos a good faith survey is not performed Perform a survey as required by WAC 296-62-07721 and RCW 49.26.13. Communicate results to employees.
Employees with potential exposure to asbestos are not provided effective training. Provide training as required under WAC 296-62-07722.
A written energy control program ( lock out/tag out program) has not been developed. Establish a written energy control program as required by WAC 296-803-20005.
A written Emergency response Plan has not been developed Where there is a risk of uncontrolled releases of hazardous substances develop an Emergency Response Plan as required under WAC 296-824.

a)Signage which restricts entry and directs employees to the nurses station was not posted to prevent the employee from entering the suspected Tuberculosis (TB) patient’s room.

b)HVAC Engineers were not required to wear respirators when they worked inside of TB isolation room exhaust air ducts while the isolation room housed suspect or confirmed TB patients.

c)Air from the exhaust ventilation for TB isolation rooms was not exhaustd away from populated areas.

d)The exhaust ventilation for TB isolation rooms shared common ducts with other rooms/areas of the facility and was not filtered.

The employer did not ensure that an employee wore eye protection such as safety goggles or a face shield when working with corrosive chemicals.
A written energy control program (also know as lock out tag out program) was not included and implemented in the employer’s existing program.
The accident prevention program did not include a section on workplace violence prevention.
A written respiratory protection program for was not developed.
An asbestos good faith survey was not performed.
An effective bloodborne pathogens (BBP) exposure control plan was not established for the hospital.
  • Develop and implement an exposure control plan for your hospital that follows the requirements of WAC 296-823-110 (244 KB PDF).
  • Update the plan at least annually to reflect new or modified tasks or procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.
  • Contact Pam Cant at 360-902-6457 or
Personal protective equipment (PPE) for potential exposure to bloodborne pathogens (BBP) or other potentially infectious material (OPIM) was either not provided or not used properly. In addition, a general assessment for hazards requiring the use of PPE was not effectively performed.
  • Perform a PPE assessment as required by WAC 296-800-160 (1.49 MB PDF).
  • Follow the specific requirements for providing and using PPE, such as those requirements found in WAC 296-823-150 (244 KB PDF).
  • Documentation of your PPE hazard assessment may be included in the BBP exposure control plan or other external document as long as it is referenced in the exposure control plan.
  • Contact Pam Cant at 360-902-6457 or
An effective program for communicating the hazards of chemicals to employees was not established.
An emergency washing facility was not provided in areas where employees mix toxic chemicals.
A safety committee with employee representation was not established.
Frequent problems identified in hospital elevator inspections:
  • Phones: inoperative, stating wrong location.
  • Test logs: missing, incomplete.
  • Failure to test smoke alarm system annually.
  • Operating Permits: not posted, expired.
  • Wet pits.
  • Emergency lights/alarm inoperative.
  • Door detector edges not functioning properly.
  • Materials stored in machine rooms.
  • Keys for elevator operation not on job site.
  • Intercom not working properly.

Frequent problems identified in inspections of boilers and pressure vessels at hospitals:

  • Boiler Controls.
  • Boiler Piping and Other Systems.
  • Boiler Manufacturing Data.
  • Report/Nameplate.
  • Boiler Components.
  • Pressure-Relieving Devices for Boilers.
  • Pressure Vessels.
  • Repairs and Alterations.
  • Failure to obtain inspection and failure to pay inspection fees.
  • Careful professional attention to and maintenance of the areas of concernand timely and complete inspections can actually prevent accidents by identifying problems and enforcing repairs prior to adverse conditions occurring.
  • Contact the Boiler program.

Frequent problems identified in inspections at hospital construction sites:

1. Contractor not registered, bonded and insured in Washington.

  • A general contractor must maintain a $12,000 bond. A specialty contractor, such as a painter, must maintain a $6,000 bond. Dissatisfied consumers may pursue restitution with civil action in Superior Court against a contractor’s bond.
  • All registered contractors must carry general liability insurance coverage ($50,000 property damage and $200,000 public liability or $250,000 combined single limit).

2. Contractor does not have a current business license.

  • Contractors are also required to have a current business license.

3. Contractor is not up-to-date on workers' comp premiums for any employees.

  • If the contractor has employees, he or she must have a federal employer identification number (EIN) and industrial insurance. (The identification number is optional for a sole proprietorship with no employees.)

4. Medical Gas and Vacuum systems.

  • Medical gas Systems and Equipment must be installed by qualified Journeyman Plumbers who have been issued a Medical gas endorsement by the Department of Labor & Industries.
  • Visit L&I's Construction Compliance website.
  • Visit your local L&I office or call the toll-free contractor registration hotline (1-800-647-0982) to learn the following:
    • If a contractor is currently registered.
    • How long the contractor has been registered.
    • If action against the contractor's bond is pending or has been taken in the past.
    • Other business names under which a contractor may have operated.
    • Whether a contractor has industrial insurance coverage for his or her employees.
  • Contact the Contractor program.

Frequently written Electrical Corrections issued at hospitals and other identified issues:

See attached document (35 KB PDF).

  • It's apparent that some of the issues that are found upon inspection of actual installations at Hospitals; might be avoided by properly submitting all new installations, and alterations to existing installations, to Electrical Plan Review. This is already a requirement, but not always adhered to. Full adherence to the rule would help avoid potentially unsafe situations and could save time and dollars as well, if costly repairs are needed.
  • It is also apparent that from Electrical Inspection’s perspective, having at least one person that could serve as a point-of-contact, would help immensely. Ideally that person would have not only the responsibility of interfacing with electrical inspection, but also the authority to ensure that all electrical installations or modifications at a facility were done in a code compliant manner.
  • Contact the Electrical Program.
  • Call the Electrical Plan Review section – Bill Eckroth, 360-902-5246.


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