Health and safety

Introduction

It seems incongruous that a service set up to provide emergency care sometimes causes harm to the staff involved in delivering that care. In 2003, the National Audit Office carried out a survey on health and safety risks to staff in the NHS in England (National Audit Office 2003a). They reported that there were 135 172 staff accidents in 2001–2, with wide variations between similar Trusts in the number of accidents per 1000 staff. They also highlighted that there is significant under-reporting, so the true figure is likely to be much higher. In 2009 a comprehensive review into the health and well-being of the NHS workforce found that NHS staff have a greater propensity to work-related illness or accident than other comparative groups (Department of Health 2009). This is despite the complex set of statutes and regulations, some based on European legislation, designed to provide a safe environment for employees and others, such as patients, visitors, contractors’ employees and agency staff. This chapter considers various aspects of accidents at work, describes the main legal responsibilities of employers and employees, and also how this legislation is applied to hazards found in emergency departments (EDs).

Preventing accidents

The Health and Safety Executive (1993) use the term ‘accident’ to refer to any unplanned event that results in injury or ill health of people, or damage or loss to property, plant, materials or the environment, or a loss of business opportunity. Before any action can be taken to prevent accidents, the causes must be identified. Causes can be divided into unsafe conditions (e.g., wet floors, trailing cables, insufficient manual handling aids, faulty equipment) or unsafe acts (e.g., nurses’ failure to wear protective equipment or ignoring safety instructions). Unsafe acts arise from lack of training or nurses’ attitudes towards their own safety (Lynch & Cole 2006). Workplaces should be regularly inspected to check that hazards do not exist and, although trade union safety representatives have this as part of their role, it should be a cooperative process between staff, managers and safety representatives. Local policies should encourage nurses to report hazards before accidents occur so that preventive action may be taken. In fact there is a specific duty contained within the Management of Health and Safety at Work Regulations 1999 (Health & Safety Executive 2000) that requires employees to report to their employer details of any work situation that might represent a serious and imminent danger.

If an accident does occur, accurate records are needed. From the employer’s point of view there is a duty to report certain types of accidents defined within the Reporting of Injury, Diseases and Dangerous Occurrence Regulations (RIDDOR) (1995) to the Health and Safety Executive. Failure to do so is a criminal offence. The employer needs information about an accident so the event can be investigated to prevent its recurrence and risk assessments can be reviewed. Employees are obliged to report accidents and it is in their interests to accurately complete accident forms and accident books to protect themselves in the event of future loss of income or long-term effects of injury or disease.

It has always been difficult to arrive at the true costs of accidents, and yet this information could provide an incentive to tackling the problem of workplace accidents by providing a measurement against which financial loss can be judged. The National Audit Office (2003a) survey of health and safety in hospitals estimated that accidents cost the NHS ≤173 million in England alone. This is a crude estimate and does not include staff replacement costs, medical treatment costs or court compensation, so the true costs are likely to be much higher. The cost of an accident is directly related to the outcome of that accident, but this can be difficult to predict, as, for example, a needlestick injury may or may not result in a nurse contracting a blood-borne virus such as hepatitis C. The total cost of accidents must include the cost of maintaining a safe environment. A relationship exists between underlying safety control and accident occurrence.

Implementing safety controls will involve some cost, such as staff communication and training, physical protection (alarm systems), publicity campaigns, time spent in risk assessment, inspecting the workplace for hazards and maintenance of equipment. These costs will be offset by the direct and indirect costs resulting from accidents and ill health, such as occupational sick pay, equipment damage, disruption in patient care, damage to the environment, costs of replacement staff and costs of litigation. The management responsibility is to reduce risks as far as is ‘reasonably practicable’, a term used in health and safety law that is a balance between the level of risk and the time, trouble and money needed to control it.

Legislation

The health service was not covered by any health and safety legislation until 1974 when the Health & Safety at Work etc. Act was passed. This is still the major legislative power and any new regulations come under its framework. The Health & Safety at Work etc. Act (1974) specifies the duties of the employer with the general requirement to ‘ensure, so far as is reasonably practicable, the health, safety & welfare at work of all his Employees’ (Section 2(1)). The Act then specifies the particular areas where this duty applies (Box 40.1).

Box 40.1 Duties of employer in the Health & Safety at Work etc. Act 1974

• The provision of plant and systems of work that are without risk to health and safety. In addition, the equipment must be maintained so it remains safe. This could include systems of handling and moving patients, infection control procedures or extraction systems to remove hazardous fumes

• Making arrangements in the use, handling, storage and transport of articles and substances so that the risk is minimized. The safe disposal of clinical waste including sharps would be covered by this requirement

• Providing information, instruction, training and supervision so that employees are kept safe at work. General training on health and safety must be provided along with specific training on particular hazards of handling of loads and fire procedures

• Providing and maintaining a safe place of work so that there is adequate heating, lighting, ventilation and fire exits

• Provision of adequate welfare facilities. Welfare is a very broad area but could include access to occupational health services, vaccination against hepatitis B, facilities for changing, showers and toilets and a smoke-free working environment

Another section of the Health & Safety at Work etc. Act (1974) defines the duty of the employer to non-employees, including patients, visitors and contractors’ employees, to ensure these people are also protected from harm whilst they are on the premises. Systems of work must be developed to protect these groups. Floor cleaning is an example of the need to ensure that staff and others are prevented from walking on wet, slippery floors by cleaning during quiet periods, temporarily rerouting pedestrian walkways or the use of cones and warning signs.

The approach to health and safety legislation is to involve both employers and employees. The Health & Safety at Work etc. Act (1974) specifies that all employees must take reasonable care for the health and safety of themselves and others who may be affected by their acts or omissions and cooperate with the employer to enable compliance with statutory requirements. If the employer provides any protective equipment, such as gloves, goggles or aprons, the employee must wear it. This presumes the employer has defined the need for the equipment, the equipment is suitable and the employer has trained staff in the correct use.

The Health & Safety at Work etc. Act (1974) is a wide-ranging piece of legislation and one that permits further regulations to be developed that refer to specific aspects of health and safety. In 1992, six new sets of regulations were enacted that were based on EC Directives (Health & Safety Executive 1992a–e), but during that period, 1974–1995, other regulations included:

• Safety Representatives & Safety Committees Regulations (1977), which define the rights and functions of trade-union-appointed safety representatives and the arrangements for safety committees

• Health & Safety (First-Aid) Regulations (1981), which provide a framework for the provision of first aid arrangements for employees. Even in emergency departments procedures need to be defined for staff who suffer an accident

• Reporting of Injuries, Diseases & Dangerous Occurrences Regulations (1995), which specify the duty on the employer to report to the Health & Safety Executive certain categories of injuries, dangerous occurrences and designated diseases.

In the case of disease, the nature of the work is specified. Hepatitis B infection is a reportable disease for anyone who comes into contact with blood, blood products or body secretions. The regulations specify the type of dangerous occurrences that must be reported, whether or not anyone has been injured. Similarly, the specific types of injury are defined along with a broad category of any injury that results in absence from work for seven days or more. The other reportable major injuries are outlined in Box 40.2. Any incidents where a staff member has a needlestick injury where the sharp was known to be contaminated with infected blood must be reported to the Health and Safety Executive under RIDDOR.

Box 40.2 Reportable major injuries under RIDDOR (1995)

• Fracture other than to fingers, thumbs or toes

• Amputation

• Dislocation of the shoulder, hip, knee or spine

• Loss of sight (temporary or permanent)

• Chemical or hot metal burn to the eye or any penetrating injury to the eye

• Injury resulting from an electric shock or electrical burn leading to unconsciousness or requiring resuscitation or admittance to hospital for more than 24 hours

• Any other injury leading to hypothermia, heat-induced illness or unconsciousness or requiring admittance to hospital for more than 24 hours

• Acute illness requiring medical treatment or loss of consciousness arising from absorption of any substance by inhalation, ingestion or through the skin

• Acute illness requiring medical treatment where there is reason to believe that this resulted from exposure to a biological agent or its toxins or infected material

Control of Substances Hazardous to Health Regulations (2002)

The Control of Substances Hazardous to Health (COSHH) Regulations (2002) was implemented in response to concerns about the effect on health of exposure to hazardous substances and replaced and revoked the earlier COSHH Regulations (1988). Dangerous substances must be categorized in terms of hazard and risk. A hazardous substance is one that has the potential to cause harm. The risk is the likelihood that it will cause harm in the actual circumstances where it is used. The regulations require the employer to carry out an assessment of the risk and subsequently to establish a safe system of work. The definition of a hazardous substance is any solid, liquid, gas, fume, vapour or microorganism that can endanger health by being absorbed or injected through the skin or mucous membranes, inhaled or digested. One exclusion is substances administered as part of a medical treatment, although the impact on the healthcare worker would need to be assessed, for instance, during the preparation of cytotoxic drugs.

Once the assessment has been carried out, steps must be taken to prevent or at least control exposure. Elimination of the substance is the ideal solution to the problem, but there will be circumstances where this is not reasonably practicable. Glutaraldehyde, a potent cause of occupational asthma, used to be the most effective cold disinfectant available but has been substituted by less hazardous chemicals or even cold sterilization (Royal College of Nursing 2000). Examples of measures to control exposure include local exhaust ventilation, enclosing the process or, as a last resort, personal protective equipment such as goggles, masks and gloves. The regulations require the control measures to be properly used and maintained and for employees and non-employees to be informed, instructed and trained in what the risks are and how to control them.

Where nurses are exposed to risk there is a requirement to carry out health surveillance. Health surveillance is needed to protect the health of individuals by detecting adverse changes attributed to exposure to hazardous substances at the earliest possible stage. This will help in assessing the effectiveness of control measures. Where health surveillance is carried out, the employees’ health records must be kept for 30 years.

Within EDs and fracture clinics there are three main areas of risk where COSHH assessments should be carried out. The first is chemical exposure, including drugs and plaster of Paris dust. The assessment and subsequent control measures should consider storage, local ventilation, waste disposal, need for personal protective equipment, training and air monitoring. Special attention should be paid to the type of environment and the potential for patients, accompanying relatives and children to gain unauthorized access to materials such as antiseptics.

The second group of substances comprises the disinfectants such as phenolics, hypochlorites, glutaraldehyde alcohol mixtures and idophors. Many of these can be an irritant to the skin and eyes.

The third group of hazards involves the microbiological hazards from contact with blood-borne infections such as human immunodeficiency virus (HIV), hepatitis B and hepatitis C that can be found in blood and body fluids of an infected patient. COSHH requires employers to assess the risks of infection and put measures in place to reduce the risks. Standard (universal) precautions such as hand washing, use of protective equipment such as gloves and goggles and decontamination of surfaces reduce the risks to both patients and staff (UK Health Departments 1998, Royal College of Nursing 2012).

However, care must be taken when decontaminating surfaces following spillages. Chlorine-releasing disinfecting agents used in spillages of urine can be used as an example of the application of COSHH. The indiscriminate use of powdered or granular products designed to disinfect and contain spills of body fluids can lead to ill effects in staff and patients through exposure to chlorine. The use of such a substance must be controlled so it does not become a greater danger than the risk of infection. A COSHH assessment in this instance would consider both biological and chemical hazards. It would take into account the urgency of any situation, the nature of the spillage, the quantities that might be spilt and the degree of ventilation. With this information a system of work may be defined to cover storage, handling and use of any disinfecting agent, the procedure for dissolving or diluting it before use and the need for any personal protection for the user.

Legislation since 1992

Health and safety is an issue that has featured prominently in European legislation. Article 118A of the Single European Act 1986 (European Union 1986) states that member states shall pay particular attention to encouraging improvements especially in the working environment as regards the health and safety of workers and shall set as their objective the harmonization of conditions in this area, whilst maintaining the improvements made.

Directly arising out of this article was a framework directive (EC Directive 89/391/EEC 1989) on health and safety, with a number of so-called ‘daughter directives’ covering manual handling, personal protective equipment, work equipment, the workplace, temporary workers and display-screen equipment. Once these directives were agreed, European Union member states were required to include the provisions of the directives into their own law by 1992. In the UK, this resulted in a set of regulations often referred to as ‘the six pack’, comprising:

• the Management of Health & Safety at Work Regulations 1999 (Health & Safety Executive 2000)

• the Manual Handling Operations Regulations 1992 (Health & Safety Executive 1992a)

• the Display Screen Equipment Regulations 1992 (Health & Safety Executive 1992b)

• the Personal Protective Equipment Regulations 1992 (Health & Safety Executive 1992c)

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