Elements of a Bloodborne Pathogens Program Part One


The hazards of Bloodborne Pathogens are still out there waiting for the next victim. In today’s workplace, we still have janitorial staff and maintenance employees among others that may come in contact with these pathogens during their daily tasks. In this series of blog posts, I will layout guidance to ensure that the minimal acceptable requirements of the Occupational Safety and Health Administration are being applied. Due to the nature of the exposure, I will not address hospitals or dental facilities.

To begin with, each organization must determine if any employees in that organization during the ordinary course of their job may be exposed to human body fluids that may contain Bloodborne Pathogens or diseases that are carried by body fluid.  The employees, who may become exposed are at risk for contracting the disease in the fluid. If your organization has employees with occupational exposure, a written Exposure Control Plan must be developed to eliminate or minimize employee exposure.

The Exposure Control Plan shall contain the following elements:

  • Exposure determination (list of employees and positions which may be exposed to body fluid through on-the-job tasks)
  • The schedule and method of implementation for methods of compliance,
  • Hepatitis B vaccination and post-exposure evaluation and follow-up,
  • Communication of hazards to employees,
  • Recordkeeping.

A copy of the Exposure Control Plan must be accessible to employees who may be exposed. Like all other safety plans the Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.


As with any safety program, the bulk of the work is to be done by the directors and supervisors in the organization. Bloodborne Pathogens is an area that I recommend they contract for the work to be done. To begin the process the directors and supervisors will conduct an assessment to determine if occupational exposure may occur to employees within the organization. If exposure may occur; these directors and supervisors will develop an exposure plan for those employees who may be exposed. The directors and supervisors will ensure employees who may be exposed receive initial and annual training on Bloodborne Pathogens. The directors and supervisors will:

  • Cause regular inspections to determine the continued effectiveness of the program.
  • Ensure employees under their supervision are provided both environmental and personal protective equipment necessary.
  • Ensure employees know their rights for taken the Hepatitis Vaccination.
  • Maintain training records to document completion.
  • Refer employees who may have been exposed to body fluids to the occupational health nurse or the local hospital for vision screening. Records of referrals for each identified employee shall be maintained separately from medical records for administrative control.

The Safety Office should not do the work to develop a program. The safety office should provide oversight and audit the program. The safety office personnel will:

  • Assist directors and supervisors in identifying specific tasks that may allow for exposure.
  • Review organizational control plans for completeness.
  • Examine the accuracy and completeness of this program during all inspections and surveys.

If the organization has an occupational health nurse, they will:

  • Assist directors and supervisors in the identification of tasks that may cause exposure.
  • Review unit or organizational control plans for accuracy and completeness.
  • Provide training to employees who may be exposed.
  • Assist directors and supervisors in determining which items of protective clothing and equipment are appropriate for the hazard.
  • Arrange for proper tests and evaluations for a person who is believed to have been exposed to body fluids.
  • Provide follow-up for employees who have been exposed.
  • Arrange for Healthcare Provider opinion of possible exposure.
  • Maintain medical records and record all exposures.

Employees assigned to work in jobs that might come in contact with human body fluid will keep protective clothing and equipment clean, properly fitted, and in serviceable condition. They will also adhere to standard operating procedures. They will also warn others of known hazards or failure to observe safety rules.


About Fred Fanning Author

Fred Fanning currently writes biweekly on his blog fredefanningauthor.com. His published works include the peer-reviewed book Basic Safety Administration-A Handbook for the New Safety Specialist. Fred also authored two editions of the peer-reviewed chapter Safety Training and Documentation Principles that was published in the bestselling Safety Professional Handbook and the Safety Professional Handbook Management Applications. He coauthored the peer-reviewed chapter Safety Training with Christine Fiori, Ph.D., PE, published in the bestselling Construction Safety Management and Engineering, second edition edited by Darryl C. Hill, Ph.D., CSP. Fred also has several self-published books. He has a series called Fred’s Safety Shorts. This is a collection of twelve books on topics related to safety published with Kindle Direct Publishing. Fred self-published another six books using both CreateSpace Independent Publishing Platform and Kindle Direct Publishing. He has authored fifty-eight articles in various publications on the topics of safety and health and project management. Fred has earned several writing awards for his non-fiction work. Fred has two novels A Walk Among the Dead and Mystery at Devil’s Elbow.
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