A Guide to Occupational Health & Safety:

Worker Orientation Manual

References
1. Public Sector Health & Safety Association: Health and Safety Resource Manual: Essential Tools
and Information
2. OHSA and Regulation (OHSA)

Occupational Health and Safety Department

Effective: October 2018

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 Table of Contents
CHAPTER 1: INTRODUCTION ......................................................................................................................... 3
CHAPTER 2: LEGISLATION & RESPONSIBILITIES ........................................................................................ 4
CHAPTER 3: MANAGING HAZARDS IN THE WORKPLACE ........................................................................... 7
CHAPTER 4: ACCIDENT INVESTIGATIONS AND INJURY REPORTING ........................................................ 9
CHAPTER 5: WHMIS ...................................................................................................................................... 10
CHAPTER 6: PERSONAL PROTECTIVE EQUIPMENT .................................................................................. 11
CHAPTER 7: SAFE WORK PRACTICES/POLICIES/MEASURES .................................................................. 13
CHAPTER 8: OCCUPATIONAL HEALTH........................................................................................................ 17
REVIEW OF SAFETY RULES ......................................................................................................................... 20

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 Chapter 1: Introduction
Every person who works at Thunder Bay Regional Health Sciences Centre (the Hospital) has an important role
to play in maintaining high standards of safety. The information in this manual is provided to assist employees
in maintaining those high standards. This manual is intended to outline the basic requirements of an effective
occupational health and safety program. It covers a wide variety of topics, but it is not entirely comprehensive.
In many cases it will be necessary to augment the information presented here with procedures and training
specific to the needs of your Program or Department. Every employee is encouraged to read this manual and
to incorporate safe practices in their work.

We welcome your recommendations to improve both this manual and the Hospital’s safety programs. Please
forward your comments and suggestions to the Occupational Health & Safety (OH&S) Department, or to a
member of the Joint Occupational Health and Safety Committee (JOHSC).

All members of the workplace have legal obligations under the Occupational Health and Safety Act (OHSA) of
Ontario for workplace safety. This manual will assist you in fulfilling these obligations and serve as a training
and resource document.

We expect that you will at all times while at work:

 Practice and promote safe work habits;
 Use personal protective equipment as required;
 Report any unsafe acts or conditions to your supervisor; and
 Work in compliance with the OHSA and the Hospital’s safety policies & procedures.

This manual will be reviewed in part with all staff at their mandatory general orientation session. The OH&S
Department is responsible for providing guidance to the Hospital on all aspects of occupational health and
safety.

Topics outlined in this manual are more exhaustively reviewed on our website on the iNtranet. Should any
question arise, contact the OH&S Department at extension 6240.

Occupational Health and Safety policies can be viewed on the iNtranet. To view OH&S policies, select the
“Departments” tab on the iNtranet. Then click on “Occupational Health and Safety” on the left hand side of the
page. Select “Policies”.

Occupational Health, Safety, and Psychological Wellness Policy Statement

The Hospital’s Occupational Health, Safety and Psychological Wellness Policy Statement is annually reviewed
and signed by the President. It states the Hospital’s commitment to provide a healthy and safe work
environment for all staff, students, and visitors. The policy can be found on the OH&S Bulletin board, located
on level 1, and on the OH&S Department bulletin board.

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 Chapter 2: Legislation and Responsibilities
The Occupational Health and Safety Act and Regulations
The OHSA came into force on October 1, 1979 (enacted to protect workers). The OHSA provides the basic
framework for making Ontario’s workplaces safe and healthy. The OHSA:
 Fosters the internal responsibility system (meaning everyone is responsible for safety) in several ways
by requiring: a joint health and safety committee; employers to have a health and safety policy and
program; and by making officers of a corporation directly responsible for health and safety.
 Imposes both general and specific duties on the workplace parties (employer, supervisors, and workers)
to protect health and safety.
 Gives workers three basic rights, the right to: know and receive training about potential hazards;
to participate in resolving health and safety concerns; and, to refuse unsafe work.
 Sets out penalties for contravention’s and provides inspectors with broad powers to inspect
workplaces, investigate accidents and complaints, and issue orders for compliance.
Where can I find a copy of the OHSA?
A copy of the OHSA is available on the iNtranet. Click on “Departments” at the top of the page. Then click on
“Occupational Health and Safety” to the left of the page. Click on “Safety” to the left of the page and then click
on “OH&S Act/Regulations”. The OHSA can also be found on the OH&S bulletin board, located on level 1, and
on the OH&S Department bulletin board.

Regulations under the Occupational Health and Safety Act

The OHSA gives the Ontario Government broad powers to make regulations. The regulations for Health Care
and Residential Facilities (O. Reg. 67/93) and Industrial Establishments (O. Reg. 851/90) are the primary
regulations that apply to activities here at the Hospital. However, different departments within the workplace
introduce different hazards and risks. In some cases, regulations beyond those for Health Care and Residential
Facilities and Industrial Establishments may apply.

Definitions from the Occupational Health and Safety Act and Regulations
A workplace is any land, premises, location or thing at, upon, in or near which a worker works. This would
also include those areas outside of the Hospital where activity may be taking place.
An employer is a person who employs one or more workers or contracts for the services of one or more
workers and includes a contractor or subcontractor who performs work or supplies services. The Hospital is the
employer for staff, students and contract workers. In practice, senior administrators and Managers act as
agents of the employer and perform many of the duties of the employer.
A supervisor is a person who has charge of a workplace or authority over a worker. Directors and Managers,
as well as supervisors and coordinators, are defined in this role.

Workers: Under the OHSA, A worker is:

1. A person who performs work or supplies services for monetary compensation.
2. A secondary school student who performs work or supplies services for no monetary compensation
under a work experience program authorized by the school board that operates the school in which the
student is enrolled.
3. A person who performs work or supplies services for no monetary compensation under a program
approved by a college of applied arts and technology, university or other post-secondary institution.
4. A person who receives training from an employer, but who, under the Employment Standards Act,
2000, is not an employee for the purposes of that Act because the conditions set out in subsection 1 (2)
of that Act have been met.
5. Such other persons as may be prescribed who perform work or supply services to an employer for no
monetary compensation; (“travailleur”)”.
6. Not a volunteer.

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A competent person means a person who:
 is qualified because of knowledge, training, and experience to organize the work and its performance.
 is familiar with the provisions of this Act and the regulations that apply to the work.
 has knowledge of any potential or actual danger to health or safety in the workplace.

A critical injury (O. Reg. 834) is defined as an injury of a serious

nature that:
 places life in jeopardy.
 produces unconsciousness.
 results in a substantial loss of blood.
 involves the fracture of a leg or arm but not a finger or toe. Refer to Policy # OHS-os-
200 Internal Responsibility
 involves the amputation of a leg, arm, or foot but not a finger or toe.
System to learn more about
 consists of burns to a major portion of the body.
everyone’s responsibilities
 causes the loss of sight in an eye. under the Occupational
Employer Responsibilities (section 25 & 26 of the OHSA) Health and Safety Act.
 Ensure that the OHSA and the Regulations are complied with,
 Supervise workers to protect their safety,
 Not employ underage workers,
 Provide and maintain prescribed personal protective equipment,
 Appoint “competent” persons as supervisors,
 Inform a worker or a person with authority over a worker, about any hazard in the workplace,
 Assist the Joint Health and Safety Committee in carrying out its duties,
 Prepare and review at least annually, a written health and safety policy and establish a program
to implement it,
 Take every precaution reasonable for the protection of the worker (this is the definition of Due Diligence).

Supervisor Responsibilities (section 27 of the OHSA)

 Ensure that the worker complies with the OHSA and the Regulations,
 Ensure that the required equipment, protective devices or clothing is used and/or worn by the worker,
 Advise the worker of any health or safety hazards,
 Provide written instruction for the workers protection,
 Take every precaution reasonable for the protection of the worker (this is the definition of due diligence).

Worker Responsibilities (section 28 of the OHSA)

 Work in compliance with the OHSA and the Regulations,
 Use or wear the equipment, protective devices and/or clothing required by the employer,
 Report to their supervisors all hazards which they are aware which are in violation of the OHSA or
Regulations,
 Report to their supervisors any known violation of the OHSA or Regulations,
 Not remove or make ineffective any protective devices required by the employer or by the Regulations,
 Not use or operate any equipment or work in a way that may endanger themselves or another worker,
 Not engage in any prank, feat of strength, unnecessary running or rough and boisterous conduct.

A Joint Occupational Health and Safety Committee is an advisory group of worker and management
representatives, whose existence is a legislative requirement of the OHSA. The workplace partnership to
improve health and safety depends on the JOHSC. It meets monthly to discuss health and safety
concerns, review progress and make recommendations to the employer. Refer to Policy # OHS-os-201 to
learn more about the JOHSC responsibilities.

Management must respond to recommendations that are made by the committee within twenty-one days, with
either a schedule for implementation or a statement of reasons for the disagreement. The committee will report

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to the Senior Leadership Council (SLC). The SLC representative on the committee is responsible for ensuring
that a response is communicated back to the team.

Some of the roles and responsibilities of a JOHSC include:

 Identification, evaluation and recommendation to management on health and safety procedures for the
workers,
 Inspection of the workplace, as legislated and identify workplace hazards
 Encouragement of safety education,
 Participation in investigations of work refusals, accident investigations and hazardous situations,
 Review accident and injury data to identify trends and to recommend changes
 Identification of potential or existing hazards,
 Review the programs, measures, and procedures on an annual basis that relate to worker occupational
health and safety,
 Promotion of occupational health & safety awareness, by providing education and training programs for all
employees,
 Monitoring programs, measures and procedures respecting the health and safety of the worker
obtaining information from the employer,
 Making recommendations to the employer for the improvement of health and safety,
 Investigating work refusals as well investigating serious injuries.

For information on the committee, a list of committee members, copies of minutes or to view recommendations
made, go to our site on the local iNtranet and follow the link to Joint Occupational Health and Safety
Committee or visit the OH&S Department.

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 Chapter 3: Managing Hazards in the Workplace
Workers in Ontario have the right to refuse work that they believe to be unsafe or dangerous. In general,
workers can refuse work if they have reasonable grounds to believe that the job they are performing or are
asked to perform poses a danger either to themselves or another worker.
There are certain conditions where the right to refuse unsafe or dangerous work may not apply. These may
include tasks where the dangers cited are an inherent part of the job (e.g. police officer), or where the health
and safety of a patient may be jeopardized. The OHSA limits the right to refuse for healthcare workers if
refusing to work could endanger the life, health or safety of another individual or if the reason to refuse is
inherent in the worker’s work or is a normal condition of the worker’s employment.

Where the right to refuse unsafe or dangerous work is covered by legislation, the legislation also protects
workers from any reprisals by the employer due to a work refusal.
Reporting Hazards
Hazards need to be reported immediately to your supervisor. You do not, and should not, wait for a formal
inspection of the area to occur or expect someone to deal with the hazard. In fact, health and safety legislation
requires all workers to report hazards to their immediate supervisor.
The supervisor will promptly investigate the reported hazard or concern and keep the employee apprised of the
progress. A response to the hazard concern could include the elimination of the hazard, a substitution to lessen
or reduce the hazard, or the implementation of an action plan. Refer to Policy # OHS-os-203

Reprisals against a Worker is Prohibited

The OHSA prohibits the employer or persons acting on behalf of the employer from taking any action against a
worker who has acted in compliance with the OHSA or any regulation. The OHSA specifically prohibits:
dismissal or threats to dismiss; discipline or threats to discipline; imposition of any penalty or; intimidation or
coercion.

Workplace Refusal Procedures

The procedure for handling health and safety concerns raised by staff consists of five possible steps. An
employee has the option of initiating the process at either step 1 or step 4. It is expected that all employees will
initiate the process at step 1 and that supervisors will take action to health and safety concerns raised by the
employee.

An employee has the right to refuse to initiate the process at step 4. If the work refusal process reaches or is
initiated at step 4, the procedures are legislated by the OHSA and covered here. Refer to Policy # OHS-os-
204.

Step 1 – Expression of Concern

Supervisors should encourage employees to discuss health and safety concerns with them. The supervisor
and employee should have a frank discussion of the concern and attempt to resolve the issue.
Step 2 – Referral to Line Management
If the supervisor and the employee are unable to resolve the issue, the supervisor should refer the problem to
the next level of supervision. If no agreement is reached at this level then the issue may either be referred to
higher levels of management or it must proceed to step 3.
Step 3 – Referral to Joint Health and Safety Committee
Where the employee or the supervisor refers an issue to the JOHSC, then the committee should investigate
the matter and submit its written recommendations to the responsible Manager and to the OH&S Department.
The responsible line Manager must respond in writing to the written recommendations of the JOHSC within 21
days giving either a timetable for implementing the recommendations or stating the reasons why he/she does
not agree with them.
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Step 4 – First Formal Work Refusal; First Stage Refusal Investigation
Procedures to be followed in the event of a formal work refusal are outlined in the OHSA. They are mandatory
and supervisors will contact the Occupational Health and Safety Nurse for assistance.
 A worker reports his/her refusal to work to his/her supervisor, because he/ she believe the
work endangers himself or a co-worker or work is in contravention of the OHS Act.
 The supervisor shall immediately investigate the situation in the presence of the worker and
worker safety representative and the certified members of the joint health and safety committee.
 A written record of the occurrence and the results of the investigation must be made and a copy sent to the
Occupational Health and Safety Nurse.
 Until the investigation is completed the worker shall remain in a safe place near his/her workstation.
Refused work can not be assigned to another worker, until first stage investigation is complete and the
circumstance of the refusal is explained to the next worker in the presence of the health and safety
members and the worker who refused.
 If the situation is resolved at this point, the worker will return to work.
 The worker may continue to refuse to work if he or she has reasonable grounds to believe that the work
continues to be unsafe. At this point the refusal continues to step 5.

Step 5 – Second Formal Work Refusal: Second Stage Refusal Investigation:

 The worker, the Manager, or someone acting on behalf of them shall notify a Ministry of Labour
Inspector, who will come to the workplace to investigate.
 While waiting for the inspector, the worker must remain in a safe place near the work station, unless the
responsible Manager assigns some other reasonable work during normal working hours.
 Pending the investigation and decision of the inspector, no other worker shall be assigned to do the work
under dispute unless, in the presence of a member of the joint health and safety committee who
represents workers, the second worker has been advised of the other worker’s refusal and of the reasons
for the refusal.
 The MOL Inspector will investigate the refusal to work in the presence of a representative of the employer,
the worker, and a member of the health and safety committee who represents workers. The inspector
shall give his decision in writing and this decision is final.

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 Chapter 4: Accident Investigations and Injury Reporting
All full-time, part-time, and temporary employees of the Hospital are covered under the Workplace Safety and
Insurance Act (WSIA), for injuries and illnesses resulting from their employment. Refer to Policy # OHS-os-207

Under the WSIA, the Occupational Health and Safety Act and Regulations for Health Care, the Hospital is
required to report to WSIB, within three days, of any accident resulting in either lost time from work or that
necessitates health care from a health care professional such as a physician, chiropractor, physio-therapist,
dentist or specialist.

The Ministry of Labour (MOL) also requires the employer to report all injuries in the workplace.
 If a person (worker or not) is critically injured (see definitions) or killed in the workplace, the employer
must immediately notify the MOL, JOHSC and union (if any).
 All worker injuries and incidents are reported to the JOHSC.

Injury Reporting Procedures

1. The worker must promptly obtain First Aid if needed and notify their immediate supervisor.
2. All accidents, incidents and near misses must be reported to your Manager/ Supervisor and
the appropriate electronic forms filled out immediately.
3. The Occupational Health and Safety Department is responsible for completing the WSIB Form 7 within
three days, for employee incidents. A fine will be levied by the WSIB for late submissions.

Electronic Incident Forms that you should be familiar with are:

 Employee Incident Report - Complete this electronic form if you are injured or observe a hazardous
situation and/or if you are exposed to blood or body fluids. (Electronic Employee Incident Reporting is only
available to full-time, part-time and casual employees of the Hospital. All others will need to fill out either
the Employee Incident Report or the Blood/Body Fluid Exposure Incident Report, contact Occupational
Health and Safety for further information)
 Patient Safety Report - Complete this electronic form for a security incident, property damage/loss
or when your patient or visitor sustains an injury and return it to the Quality Management department
promptly.

* Downtime forms are available if the electronic reporting system is down.

All accidents, incidents and near misses are followed up and corrective actions taken to prevent recurrence.
The supervisor ensures that preventative action is taken to prevent a reoccurrence.

Critical Injury:
Any employee who sustains a serious injury will be taken to the Emergency Department and the Occupational
Health Nurse will be notified immediately. If the result of the injury is critical, the Occupational Health & Safety
Manager will take appropriate measures as required by the OHSA.

Person in Charge at Time of Incident

1. Immediately obtain appropriate medical attention for the injured employee as required.
2. Secure the scene where the accident occurred by posting a person or barricading the area with caution
tape or rope.
3. Obtain basic information for purpose of notifications complete an employee incident form.
4. If the person in charge is not the responsible supervisor/Manager, immediately contact by phone the
supervisor/Manager or delegate and the Administration Co-Ordinator.
5. Refer to Policy # OHS-os-230

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 Chapter 5: WHMIS
What is WHMIS?

The Workplace Hazardous Materials Information

System (WHMIS) is a comprehensive national
communication system for safe management and use
of hazardous materials that is legislated by both
federal and provincial jurisdictions. Refer to Policy #
OHS-os-222

WHMIS Regulation

WHMIS legislation requires that workers must be

informed about the hazardous materials in the
workplace and receives appropriate training to enable
them to work safely. The ultimate goal of the WHMIS
program is to create a safer workplace by providing
workers with the knowledge and tools to enable them
to work safely.

To accomplish this, WHMIS requires all suppliers of hazardous materials to label and prepare Material Safety
Data Sheets (MSDS’s) for products they make, import, package, or process that meet the hazard criteria set
out in the Controlled Products Regulations under the federal Hazardous Products Act.

The buyers of these controlled products must make sure that these products are correctly labeled and that
MSDS’s are available to those using the products. Employers must set up worker education programs to
instruct workers about the WHMIS legislation, the contents and significance of labels and MSDS’s, and how to
work safely with hazardous materials.

In summary, WHMIS delivers the necessary information by the following means:

 Labels on containers of controlled products,
 Material Safety Data Sheets or SDS for each controlled product,
 Worker training programs.

Everyone has the right to know about the products that they are using at work, and that's what WHMIS is all
about. All Hospital employees receive WHMIS training during orientation, product specific training by their
Manager/ delegate when hired and annual WHMIS review. WHMIS Training can be found on the Learning
Management System.

A complete inventory of products and material safety data sheets is available on the MSDS Database.

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 Chapter 6: Personal Protective Equipment
All personal protective equipment (PPE) is designed to protect you from hazards in the workplace that cannot
be eliminated. They provide a barrier between you and the hazard. When procedures or policies require the
use of personal protective equipment they shall be provided to you by the Hospital. Refer to Policy # OHS-os-
213.

If you are required to wear PPE not mentioned here or have questions about, contact your supervisor or the
OH&S Department for additional information.

Employees are responsible for:

 Inspecting all PPE prior to its use;
 Immediately notifying their supervisor of any defect in the PPE:
 Wearing PPE upon the direction of their immediate supervisor;
 Participating in mandatory training;
 Notifying their supervisor when new PPE is necessary;
 Notifying their supervisor of any changes which might impact the type of PPE they utilize.

Hand Protection
Hand protection shall be worn when hands are exposed to hazards such blood, body fluid, chemicals, hot,
rough or sharp objects. The type of hand protection used shall be based on the risk of the task(s) to be
performed or potential hazards identified. The Hospital carries a wide variety of suitable gloves. (If problems
report to the Occupational Health and Safety Department)

Head Protection
Head protection shall be worn in areas where there is a potential for injury to the head from impact, flying or
falling objects (e.g., working below other workers who are using tools and materials which could fall through
grates), or electrical shock and burns.

Eye/Face Protection
Suitable eye protection or face protection shall be worn when there is the potential for exposure to the eyes or
face. Eye protection must be worn during procedures that are likely to generate splashes or aerosols of blood,
body fluids, or chemicals. While personal eye glasses offer some protection against splashes they are not
safety glasses and are not a substitute for them.

Safety goggles or safety glasses with side shields must be worn when working with chemicals, drilling,
using power tools or whenever the nature of the job presents a potential eye hazard. Face shields must be
worn when grinding or welding.

When using lasers, appropriate safety eyewear is a must. Different lasers require different types and shades
of eye protection. Consult your Manager for appropriate protective eyewear

Eye protection shall be durable, comfortable and easy to clean. Persons whose vision requires the use of
corrective lenses and who by nature of their job duties require eye protection shall wear goggles or a full face
shield that can be worn over the prescription lenses.

Foot Protection
Foot protection shall be worn when there is the potential for injury to the feet from falling or rolling objects,
objects piercing the sole of the foot, electrical hazards, hot surfaces and slippery surfaces. Appropriate
footwear must be worn at all times while at work. This includes a well fitted shoe, an enclosed heel and toe,
good arch support with a firm non-slip material and heel height not exceeding 2 inches. Refer to Policy #
OHS-os-211

Footwear exceptions:

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 Physical Plant, Materials Mgmt., and cleaners in Housekeeping must wear a CSA minimum grade
3 protection
 Biomedical engineers and electricians who must wear CSA Omega minimum grade 3 protection
 Staff who do not lift or transfer clients, handle blood or body fluids or chemicals, push carts or
handle chemicals or sharps are allowed to wear shoes with closed toes and heels

Hearing Protection
Hearing protection shall be worn in certain designated work areas and job tasks
CSA/ANSI approved hearing protection must be worn if you are working in areas where the sound level is 85
dBA, Lex8 or greater. Refer to Policy # OHS-os-242

Body Protection
Body protection, full or partial shall be worn when there is a potential for injury due to:
 Contamination or exposure to blood and/or body fluid,
 Heat, splashes from hot fluid,
 Chemicals and radiation.

Body protection includes, but is not limited to the following:

 Lab coats,
 Aprons,
 Coveralls,
 Isolation gowns,
 Stryker suits,
 Boot covers.

Respirators
Some employees are required to wear respirators. The proper type of respiratory equipment must be worn to
prevent inhalation of harmful amounts of dust, fumes, mists, aerosols or vapors, or infectious agents. Refer to
Policy # OHS-os-215.

Respirators include dust masks, air purifying negative pressure respirators, self contained breathing apparatus
as well as N95 respirators. Use of respirators shall be done in accordance with the Respiratory Protection
Program. If you wear one of these respirators, you must be “fit tested “and trained before using it on the job.
All staff will complete a Respirator User Screening Form prior to being fit tested. Note: As per policy, you must
be clean shaven to ensure a proper skin to mask contact.

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 Chapter 7: Safe Work Practices/ Policies/ Measures
Enforcement of Policies
Compliance with Hospital and legislated environment and safety standards is necessary to maintain a safe and
healthy work environment (which applies to all staff including contractors, physicians, students and volunteer).
As with any program, corrective disciplinary measures may be required to deal with non-compliance. This will be
dealt with according to hospital Human Resources principles. (Refer to Human Resources Policy # HR-t-04)

Standard Operating Procedures

Knowing the standard operating procedures for equipment you use will help you do your job properly and
safely. Ask for training on how to do the job properly and safely. Ask questions if you do not completely
understand how to do the job or if you have safety concerns. By knowing the standard operating procedures
you will use your equipment the way it was intended.

Workplace Inspections
Workplace Inspections are performed in order to identify hazards and recommend controls, to prevent
accidents, ensure existing controls are sufficient, to highlight training needs, establish safe work practices, and
indicate problem areas. Workplace Inspection includes interviewing staff during the walk through to identify
safety concerns. Refer to Policy # OHS-os-206

A workplace inspection is a planned walk through of a workplace or selected areas on a regular basis:
1. All departments conduct a Workplace Monthly Safety Inspection.
2. The JOHSC conducts a Workplace Annual Safety Inspection ensuring that the entire workplace is
inspected annually.
Note: All inspections can be found in departmental inspection binders.

Occupational Health and Safety Boards

The legislation requires that notices be posted in locations in the workplace where the information is readily
accessible for l workers. Therefore the boards are located in a public/common area on the first floor beside the
elevator and information is also posted on the OH&S Department bulletin board and iNtranet, as required.
Eye Wash/ Emergency Showers
Eyewash stations and/or emergency showers are available for staff. They are located in designated
departments as required. It is recommended that for most exposures a 15 minute flush of tepid water be the
choice of first aid. Refer to Policy # OHS-os-240. Know where your eye wash station is located and how to use
it before you need to use it.

Back Awareness Program

Musculoskeletal Injury (MSI) occurs more frequently than any other type of occupational injury. Employees
should strive for an environment where if assistance is required then a mechanical lifting device is to be used.
Refer to Policy # OHS-os-208, 209 & 250. At all times while working, you must follow the safe lifting and
transferring procedures. Staff is required to complete an annual review which can be found on the Learning
Management System. Note: Before you use a mechanical lift, be sure you have been trained on how to use it
properly. Refer to your Manager for operating instructions.

Workplace Violence and Harassment

Workplace Violence and Harassment Legislation requires that the employer take all reasonable precautions to
protect workers. To comply with this the Hospital has developed a program outlining steps it will take to prevent
report and address workplace violence and harassment. Refer to Policies OHS-os-245 & HR-hr-01. All
employees of the Hospital are required to review the program annual. Training can be found on the Learning
Management System.

Scented Products
Scented products, such as colognes and perfumes, must NOT be worn. Some individuals are sensitive to the
chemicals that can be found in these products and even low levels of these can trigger respiratory reactions,
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migraines, allergies or other health problems. Please respect this and do not come to work wearing fragrant
products. Remember that we all share the air! (See policies - Admin-18, HR-tce-06 and ADM-2-06)

Hand Hygiene
Hand hygiene is the single most important and effective means of preventing the spread of health-care
associated infections. As a result, the Hospital has instituted a program called, “Just Clean your Hands”. It
enables health care providers to quickly and easily fulfill the “4 Moments of Hand Hygiene”, which are: Before
initial patient/patient environment contact; before aseptic procedure; after body fluid exposure risk; and finally
after patient/patient environment contact. Contact the Infection Control Department for more information.

Contractor Safety Program

All contractors and subcontractors who are hired to perform work at the Hospital must complete the Contractor
Safety Program before beginning work on site. If you observe contractors using unsafe work practices you
should report this to your immediate Manager/designate. Contact Occupational Health and Safety Department
for a copy of program and necessary forms. Refer to Policy # OHS-os-223

Electrical Safety
To manage electrical safety, report all shocks immediately even tingles. Never work around electricity when
you or your surroundings are wet. Don’t use “octopuses”, plugging in too many cords can overload the circuit.
Do not store items in front of an electrical panel. Don’t use damaged outlets or adapters. Keep cords away
from heat and water. Don’t run cords under rugs or through doorways. Always disconnect electrical
equipment from the power source before cleaning. All electrical equipment must be approved by the
biomedical department.

MRI
Magnetic resonance imaging is formed by the combination of a strong magnetic field and radio waves with the
hydrogen atoms in the tissues of the body. Using computers, this information is made into a number of three-
dimensional pictures of the body it is one of the safest and most comfortable imaging techniques available.
However since there is a strong magnetic field present, all staff who are required to enter the room must
undergo safety training and complete a screening checklist. Screening will ensure that anyone who enters the
room has no contraindications to do so. Staff will also be made aware of the danger of injury when
ferromagnetic objects are brought into the magnet room.

Lasers
The Hospital operates lasers for medical purposes. A laser safety program is maintained in accordance with
the Canadian Laser Safety standards. A Laser Safety committee regularly meets. To contact the Laser Safety
Officers call the Manager of the Operating Room. Refer to Policy # OHS-os-227

Security
Security staff are available to staff 24 hours a day, 7 days a week Emergency panic buttons are throughout the
Hospital. Activation of these buttons will sound an alarm in the security Office. Each parking lot is also
equipped with Emergency Panic Buttons.

Chemical Spill Procedures

Regardless of who caused the spill, it is required that only employees who have had WHMIS training on the
spilled chemical will participate in the clean up. Refer to Policy # OHS-os-218

Cytotoxic Drugs
Cytotoxic drugs also referred to as antineoplastic or chemotherapeutic drugs are used to treat cancer patients.
Staff who are mixing, administering or disposing of these drugs will be trained on Safe Handling Practices of
Cytotoxic Agents & Cytotoxic Waste for Healthcare Workers. For more information, contact Pharmacy and
Academics and Interprofessional Education. Spill kits are available in the event there is a spill of these drugs.

Lockout
Lockout procedures are a set of safe work practices that reduces the likelihood of a worker coming into contact
with an uncontrolled energy source.
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Operating the emergency stop or the main stop-start button is not lockout and does not ensure that equipment
is neutralized. Any staff servicing or repairing electrical equipment must use approved lockout procedures.
Procedures and equipment for Lockout are found in the Physical Plant. Refer to Physical Plant policy – PP –
400.

Confined Spaces
A confined space is a space or area which because of its construction, location, contents or work activity
therein, the accumulation of a hazardous gas, vapour, dust or fume or the creation of an oxygen deficient
atmosphere may occur.
Only workers who have received training on confined spaces will be allowed to enter, clean, inspect or do
maintenance duties in an area considered to be a confined space. Contact Physical Plant if more information
is required. Refer to Policy # OHS-os-223

Transportation of Dangerous Goods

Transport Canada requires that any one transporting or receiving a chemical that is considered dangerous
under the Transportation of Dangerous Goods Act must be adequately trained. Only workers that have been
certified in TDG will be allowed to participate in receiving or shipping of these chemicals. Refer to Policy #
OHS-os-216

Housekeeping
A clean work area that is kept free from slipping and tripping hazards is safer for everyone. Do your part and
maintain good personal work habits. Help the housekeepers by respecting wet floor signs and walking on the
other side of the hall. If you notice a spill on the floor, wipe it up. Whenever possible, clean up after yourself.
Share in the responsibility for keeping our work place safe.

Needles and Sharps

Needles and sharps must be handled with extreme care. Never recap a needle that has been used on a
patient, ensure that the safety device on the Safety Engineered Needle is engaged and dispose of it
immediately into an approved sharps container. Only areas who have been designated may recap needles.
You are responsible for safely disposing of needles you have used. Don't leave them for someone else to
discard. Refer to Policy # OHS-os-214. Note: If you sustain a needle stick or sharps injury, report it
immediately to your Manager/delegate and the Occupational Health Nurse.

Infection Control
All staff receives training on routine precautions. Routine Precautions are an approach to preventing
disease transmission. Routine Precautions should be incorporated into everyday care. Practices should
include the use of:
 Gloves, only to be worn when likely to touch body substances, mucous membranes, or non-intact skin, or
when handling equipment that has been in contact with the above mentioned conditions
 Hand washing, before, between, and after patient contacts, and after,
 Contact with equipment contaminated by patients,
 Masks when splashes or aerosolization is likely to occur,
 Eye protection,
 Gowns/aprons,
 Proper sharps disposal,
 Linen and waste handling procedures,
 Environmental controls.

Following Routine Precautions avoids the assumption that the patient who is not suspected or known to have
a transmittable disease is free of risk to other patients and staff and that only certain body fluids are
associated with the transmission of infection. Routine Precautions protects staff during the period before a
diagnosis is known and throughout a patient stay in the Hospital.

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With the emergence of MRSA, ESBL, VRE and Clostridium difficile and the potential to contaminate the
environment additional precautions have been added to the ‘routine’ precautions that should be in place for all
patient care.

Fall Protection
Any time a worker is doing their job above ground level, the usual hazards associated with their task are
increased by the additional risk of falling. Working on elevated platforms, ladders, scaffolding, towers and
rooftops can be dangerous. Whenever a worker is performing their job 3 meters (10 feet) or more above the
ground, or when a fall from a lower height involves an unusual risk of injury, the supervisor /Manager must
ensure that a fall protection system is in place. Fall protection systems include guardrails, body harnesses and
lanyards (a safety strap attached to the body harness) and sometimes even safety nets. Contact Physical
Plant for further information.

Indoor Air Quality

We must rely on mechanical devices for the control of temperature and humidity. The ventilation systems
determine the quality of indoor air by controlling the amount of outdoor air that is added to the building
atmosphere. Outdoor intakes are located so that air entering the building does not contain contaminants in a
concentration greater than normal ambient air. Report any concerns to your Manager/ physical plant. Refer to
Policy # OHS-os-237

Noise
Noise level testing is performed for work tasks that produce significantly elevated levels of noise. Noise hazard
areas are identified and workers who may be exposed to elevated levels are required to wear hearing
protection. Base line audiometric testing is provided for new hires when required. (For nuisance noise, contact
your immediate Manager/designate)

Ladders
Inspect ladders for defects before use. If unsafe do not use, report the defect to your supervisor. Substitutes
for ladders such as boxes or crates must not be used. Place ladder on a level base before use. Stepladders
should be fully opened with spreader arms locked. Never stand on the top two rungs. When climbing you must
have both hands free to allow you to maintain three points of contact. Straight or extension ladders must be
tied off or held in place by one or more persons at all time while in use. Metal ladders must not be used when
working with live electrical apparatus or in battery rooms.

Handling/Storage of Flammable & Combustible Liquids

Staff handling flammable or combustibles will receive appropriate training. Handling and storage will comply
with the Ontario Fire Code and the OH &S Act. Storage of flammables and combustibles will depend on the
quantity and will always be identified with a flammable sign. Locations include the flammable stores the
explosion room and in approved metal cabinets. Flammable and combustible liquids will be dispensed only in
designated areas into approved safety cans. Transportation through the workplace will be done by trained
staff, on secure carts, and will be the most direct route to minimize contact with patients, staff and visitors.

Emergency Codes
Our hospital uses a color-coded system to announce Emergency codes. This is standard in Ontario hospitals.
Departmental instructions detailing what you need to do when a code is announced are included in plastic
jackets with color coded sheet inserts in all departments. Staff Education will review these with you.

ALERT 99 Person experiencing trauma

AMBER Missing, Abducted, Wandering Child
BLACK Bomb Threat
BLUE A cardiac arrest (Adult)
BROWN Unknown/Unmanageable substance
GREEN Evacuation

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 GREY Air Exclusion
NRP A cardiac arrest (Neonatal)
ORANGE Disaster Plan
PINK A cardiac arrest (Paediatric)
PURPLE Hostage Taking
RED Fire
SILVER Active Shooter/Armed Intruder
WHITE Violent Patient/Visitor
YELLOW Missing patient

Education
It is essential that you are trained on safe work procedures. If at any time while at work, you are not sure of any
aspect of the job that you are being asked to perform contact your Manager/ designate before you begin doing
the job. Refer to Policy # OHS-os-202 & Interprofessional Education Policy SE-01. Ongoing training will
depend on the type of job that you are doing. All employees will be expected to participate in mandatory
training programs annually. These include:
 Emergency codes
 Health and safety
 Back Care
 WHMIS
 Workplace Violence and Harassment
 Infection Control

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 Chapter 8: Occupational Health
In accordance with the Public Hospital’s Act and to comply with the Communicable Disease Surveillance
Protocols for Ontario Hospitals, all employees and volunteers carrying on activities in the Hospital will be
assessed by the Occupational Health Nurse within 14 days prior to or 14 days after the date of employment or
placement. All other persons carrying on activities students, physicians, undergraduate and post graduate
medical trainees, and contract workers, will provide the required documentation as per policy OHS-oh-106.
Contact Occupational Health and Safety for further information if required.

Failure to comply will result in preclusion from work. This is in accordance with
Regulation 965, Section 4 of the Public Hospital Act.

The purpose of the assessment is to ensure that persons carrying on activities in Thunder Bay Regional Health
Sciences Centre:
 are fit to perform the tasks of the position
 are immunized against communicable diseases
 provide baseline data for health file
 receive wellness counseling as required

The Occupational Health Nurse conducts a preliminary health review prior to or within 14 days of
placement/employment including:
 Health history
 Communicable disease surveillances
 Immunization status
 Baseline tuberculin skin test
 Laboratory testing
For reasons of patient safety, documented proof of immunity is a condition of employment as requested by
Ontario Hospital Association/Ontario Medical Association protocols.
At the discretion of the Occupational Health Nurse, further medical information or examinations may be
required. If so, reports must be returned to the Occupational Health Nurse prior to the expiration of the
employee’s probationary period.

IMPORTANT!
Infectious illnesses must be reported to the Occupational Health Nurse immediately, so policies can be
followed for proper management and to reduce risk to other staff and patients.

Influenza
Influenza is an acute viral disease of the respiratory tract characterized by fever, headache, myalgia,
prostration, sore throat and cough. Influenza can spread rapidly and can have widespread morbidity and have
serious complications such as viral and bacterial pneumonia.
Annual immunization is considered an essential component of the standard of care for the protection of
patients. Vaccination is provided by the Hospital in the late fall. Watch for posters in the fall advertising the flu
clinics.
If you do not receive a flu shot and there is an outbreak of influenza in the area that you work in, you will be
precluded from working.

Transitional Work Program

The Occupational Health and Safety Department provides early and safe return to work for employees who
have been injured on the job. We recognize the benefits of a transitional program and make every effort to
provide meaningful employment for employees who are either temporarily or permanently disabled.

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  Transitional work positions are any job, task, function, hours of work or combination thereof that an
injured employee may perform safely without risk of re-injury.
 The work must be productive and the result of the work must have value.
 The work must be seen as temporary, generally not to exceed 6-8 week in duration.
 Meetings are set up to develop a transitional plan with the goal to be to return the employee to full
duties

Attendance Management
Regular attendance at work is an essential duty of every job and an expectation of employment at Thunder
Bay Regional Health Science Centre. You have a responsibility to ensure that you meet this requirement. We
have an attendance management program that reviews patterns of absence. If your absences exceed the
norm, or when patterns of absences have an adverse effect on operations, it will be considered a performance
deficiency. Failure to meet attendance standards on a regular basis may lead to termination of your
employment contract. Refer to the Attendance Management Program booklet for more information.

Employee & Family Assistance Program (EFAP)

Thunder Bay Regional Health Sciences Centre has an Employee & Family Assistance Program available to all
employees. This service is strictly confidential and is available to all employees and their immediate family
members at no cost to the employee. EAP (Employee Assistance Program) provides counselling for many
concerns - and can be called if you have:
 Financial difficulties
 Relationship or marital difficulties
 Anxiety, depression, stress, tension
 Chemical dependency
 Workplace conflicts

This is just a few of their services. To contact the EFAP services - call 623-7677

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 Quick Review of Safety Rules
The following general safety rules have been developed to provide a safe and healthy working environment for all Hospital
employees. These apply to all work activities.

 Report to work well rested and physically fit to be able to give full attention to your job.
 Persons with physical or mental impairment shall not be assigned to tasks where their impairment has a
potential to endanger themselves or others.
 No person shall be permitted to remain on the premises while their ability to work is so affected by alcohol, drugs
(prescription or non-prescription) or other substance, so as to endanger their health or safety or that of any other
person.
 Inappropriate behaviour, such as horseplay, fighting and practical jokes are extremely dangerous and will not
be tolerated.
 Any unsafe conditions which are encountered shall be corrected or reported to your
immediate Manager/designate.
 Do not operate any machinery or equipment if it is known to be in an unsafe condition.
 Machinery and equipment, including vehicles, are only to be operated by qualified persons and then only
when adequately trained in the use of the equipment and authorized to operate it.
 Unsafe actions shall be reported to your immediate Manager/designate.
 Personal protective equipment (PPE) must be worn when performing specific duties that require its use to
ensure worker safety. Persons refusing to wear PPE will be subject to disciplinary action. Selection of the correct
PPE may require assistance; contact your immediate Manager/designate.
 Avoid manual lifting of patients or objects, instead get assistance or use mechanical lifts.
 Smoking is prohibited within the premises and vehicles at all times.
 Employees are responsible for reporting to their immediate Manager/designate whenever they become sick
or injured at work. All injuries must be reported.
 Always keep your work area clean and orderly. Poor housekeeping habits can be a serious safety hazard. Do
not leave materials in aisles, walkways, stairways, roads or other points of egress.
 Any damaged equipment or missing machine guards must be reported to your immediate Manager/designate.
 All warning signs signals and alarms shall be obeyed.
 Employees shall not use unfamiliar tools or equipment without proper instruction and permission from
their immediate Manager/designate. Always, use the correct tool for the job, do not improvise.
 Loose or ragged clothing, dangling neckwear or bracelets shall not be worn around moving parts of machinery or
electrically energized equipment.
 Ensure that at all times long hair is fastened back to prevent entanglement.
 Flammable liquids are to be handled and stored only in CSA approved safety containers. Proper lids and
caps must always be used on storage containers...
 Do not dispose of any hazardous materials or flammable liquids by pouring them down a sewer or drain.
Guidance in proper disposal of hazardous materials is available from the Environmental Services.
 Compressed gas cylinders should be stored in an upright position and chained or otherwise secured. Where not
connected to a service line or manifold system, the protective caps for these cylinders shall be in place.
 Compressed air shall not be used for cleaning clothing or to blow dust from your body.
 Do not attempt to repair defective wiring or other electrical equipment. Report defective electrical equipment
to your immediate Manager/designate. Electrical equipment can only be repaired or serviced by a qualified
electrician.
 Faulty or makeshift ladders must not be used.
 If something looks unsafe it probably is, report it immediately.

Thank you for your co-operation and welcome to Thunder Bay Regional Health Sciences Centre.

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