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Sample Ethylene Oxide Plan

Since ethylene oxide (EtO) is considered a potential human carcinogen by the National Institutes of Health, the leadership of this practice is very concerned with ensuring personnel who handle this chemical follow the prescribed safety procedures.

Storage of EtO

Only the individual ampules of EtO will be stored in the facility. The ampules will be stored only in their original containers in a cool, dry place. Only the minimum supply will be kept on hand at any time. The box of ampules will be stored in a closed cabinet or drawer to prevent accidental breakage or damage. When handling the individual ampules, keep the protective cushion wrapper in place until immediately before placing the ampule into a sterilization bag. NEVER set ampules on counter tops or tables since they can roll off and break.

Use of EtO Sterilizers

The hospital director will ensure that only personnel who have been trained in the proper sterilization techniques for this agent are allowed operate the equipment. The detailed operating instructions provided by the manufacturer of the sterilizer will be available on or near the machine. The instructions for loading, processing, venting, unloading and aeration will be followed.

Exposure Monitoring

Initial exposure monitoring, as required by OSHA regulations, will be completed and the results made available in the Hospital Safety Manual. If the exposure levels are found to be below the Permissible Exposure Limit (PEL) for both the 8 hour and 15 minute exposure times, no further testing is required. However, the hospital director will ensure that additional testing is performed if the procedure or personnel performing the procedure changes, or after clean-up of an accidental release of EtO into the workplace.

In Case of an Emergency

If an ampule of EtO is accidently broken outside of the plastic sterilization bag or the sterilization chamber, the following steps must be taken IMMEDIATELY:

1.  Turn off the air handling system and evacuate the area, closing doors that lead to other occupied areas.

2. Notify the safety director of the accident.

3. The safety director will consult with the Material Safety Data Sheet and or the product manufacturer to determine the correct cleanup procedures to be used. In no circumstances will staff members attempt to clean up the spill unless they have been properly trained to do so.

________________________ is responsible for ensuring the provisions of this plan are followed.