Improving Compliance With Occupational Safety and Health Administration Standards

Article Outline

• ABSTRACT
• The Occupational Safety and Health Administration
  • Adopting standards
  • Promulgating standards
  • Requiring employers to comply
• OSHA Inspections
• OSHA and Health Care
  • Reducing workplace risks
  • Bloodborne pathogens
  • PPE and health care workers
  • PPE and perioperative services
• The Rule of Law
• Implications
• Examination
  • Improving Compliance With Occupational Safety and Health Administration Standards
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Improving Compliance With Occupational Safety and Health Administration Standards
• Learner Evaluation
  • Improving Compliance With Occupational Safety and Health Administration Standards
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

HEALTH CARE FACILITIES can be dangerous places. The mission of the Occupational Safety and Health Administration (OSHA) is to improve the safety of the American workplace by developing and implementing standards that prevent occupational injury, illness, and death.

PERIOPERATIVE SERVICES are performed in environments where exposure to bloodborne pathogens is a daily occurrence, making implementation and compliance with OSHA standards very important.

EMPLOYEES AND EMPLOYERS must remain current with workplace safety requirements, including use of personal protective equipment. This article presents implications of the OSHA standards for employers, educators, and employees. AORN J 87 (February 2008) 347-356. © AORN, Inc, 2008.

Although safe conditions in today's workplace are expected, this has not always been the case for American workers. Before the creation of the Occupational Safety and Health Administration (OSHA) in 1971, more than 14,000 American workers died each year in unsafe work environments, and disabling work-related injuries increased year after year.¹ Fortunately, these statistics have improved significantly. Although not free of risk—in 2005, American workers suffered 4.2 million occupational injuries and illnesses, and 5,702 employees died as a result of accidents at work²—the American workplace has been made safer through the

When OSHA was first established, the agency primarily was concerned with agricultural, mining, and construction-related injuries or deaths. Over the years, the nature of workplace injuries and the causes of work-related fatalities have changed. Today, the four most frequent work-related fatal events are highway accidents, homicides, falls, and being struck by falling objects. The most common nonfatal injuries, resulting in days away from work, are sprains, strains, and tears. Health care workers (HCWs) are at high risk for these musculoskeletal injuries. In 2005, RNs reported 20,100 work-related injuries with the majority being strains and overexertion.²

Just as the mining, agricultural, and construction environments have changed since OSHA's inception, so has the work world of American HCWs. During the early to mid 1980s, transmissible, potentially fatal diseases became of great concern to HCWs. In response, OSHA developed standards addressing exposures to bloodborne pathogens in addition to other contemporary workplace safety concerns.¹

This article reviews OSHA's formation and describes its legal authority, duties, and responsibilities specifically as they relate to the health care industry and, in particular, the perioperative setting. In addition, the use of personal protective equipment (PPE) is discussed from a historical perspective, and OSHA requirements for employee education and monitoring are presented. Finally, relevant federal and state case law is discussed relating to OSHA, workers' compensation, educator/ employer responsibilities, and subsequent liabilities when employees choose not to wear appropriate PPE.

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The Occupational Safety and Health Administration 

In the 1960s, America's attention was focused on the Vietnam War; the assassinations of President John F. Kennedy, Sen Robert Kennedy, and civil rights leader Martin Luther King, Jr, and the safety of the US workplace. Fourteen thousand workers died from work-related injuries each year, and disabling injuries sustained in the workplace had risen 20% from the previous decade.¹ Sen Harrison A. Williams, Jr (D-New Jersey) called for government intervention to improve the safety of America's workplaces. Simultaneously, Rep William A. Steiger (R-Wisconsin) advocated for the passage of a bill to protect America's workers. In December of 1970, the Williams-Steiger Act was signed into law by President Richard M. Nixon. This act is more commonly known as The Occupational Safety and Health Act of 1970 (OSH Act).¹

The purpose of the OSH Act is “to assure, so far as possible, every working man and woman in the nation safe and healthful working conditions and to preserve our human resources.”³ To achieve this, the Secretary of Labor was authorized by Congress to

Thus, the Occupational Safety and Health Administration was formed with the mission to develop and implement standards that prevent occupational injury, illness, and death.⁴ Through establishment and enforcement of standards via inspections and the levying of monetary fines, OSHA has been able to improve the safety of the American workplace.

Adopting standards 

Recognizing that the federal legislature was ill-prepared to pass laws regarding workplace safety, Congress authorized OSHA to establish and enforce occupational safety and health standards.⁵ Not wanting to give one agency “carte blanche” with regard to rule formation, however, Congress required that OSHA follow a public-participation process similar to that of other agencies. This public-participation process, known as notice and comment rule making, is both slow and cumbersome and takes time to produce results.⁵

Promulgating standards 

Americans were sustaining occupational injuries at alarming rates, and work-related deaths were rising. Under political pressure to act, Congress gave OSHA a two-year period in which they were authorized to establish binding standards without public participation; however, OSHA could only adopt widely recognized federal standards and/or voluntary consensus standards already in place. These rules were developed by agencies such as the National Fire Protection Agency, the American National Standards Institute, and the American Conference of Governmental Industrial Hygienists.¹ To further address their constituent's concerns that OSHA would be too powerful, Congress required that these standards be adopted verbatim. Federal and voluntary consensus standards were created via procedures in which interested parties agreed to substantial portions of the rule, satisfying public concerns of possible abuse of power.⁵

Requiring employers to comply 

In 1971, OSHA published its first consensus standards limiting worker exposure to more than 400 known toxic substances. Since then, OSHA has established standards aimed at addressing contemporary issues in American workplaces, including standards to

A health or safety standard requires

conditions, or the adoption or use of one or more practices, means, methods, operations, or procedures, reasonably necessary or appropriate to provide safe or healthful employment or places of employment.³

Standards are considered to be reasonably necessary if they substantially reduce or eliminate risk of injury or death, are feasible economically and technically, and are supported by substantial evidence.⁶ The OSHA health and safety standards are mandated legally, apply to all US employers and their employees, and are enforced via inspection.

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OSHA Inspections 

Originally, OSHA focused inspections on the most dangerous workplaces and catastrophic accidents. Later, the agency refined its inspection priorities to target workplaces with significant hazards and industries with serious problems. Today, OSHA has published six inspection priorities:

Inspections can result in citations or financial penalties. After an inspection, the OSHA compliance officer submits a report of findings to the area director who determines whether citations will be issued or monetary penalties imposed. If issued, citations alert the employer and employees of standards and regulations that have allegedly been violated along with the required corrections. Employers must post citations near the area where the violations occurred for a minimum of three days or until the violation is corrected, whichever is longer. Penalties can be levied for any number of violations.

Although there are others, the three most common citations are for other-than-serious, serious, and willful violations. Other-than-serious violations are those that have a direct link to job safety and worker health but that would not likely cause serious harm or death. Serious violations are those for which there is a high probability that serious physical harm or death could occur. Willful violations are those for which the employer knows that a condition violating a standard exists and makes no reasonable attempt to eliminate it. In 1990, Congress increased the maximum penalties from $1,000 to $7,000 for other-than-serious and serious violations and from $10,000 to $70,000 for willful and repeat violations. In all instances, the agency has the authority to adjust the penalty based on the employer's history, good faith, and size.⁷ These penalties apply to all settings, including health care.

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OSHA and Health Care 

Health care facilities (eg, hospitals, outpatient surgery centers, dental offices, nursing homes, clinics) can be dangerous places. All are regulated by OSHA's general industry standards. Perioperative services, in particular, are performed in environments where exposure to bloodborne pathogens is a daily occurrence, making implementation and compliance with OSHA standards significantly important. The general duty clause of the OSH Act requires employers to

furnish to each of [their] employees employment and a place of employment which [is] free from recognized hazards that are causing or likely to cause death or serious physical harm to [their] employees. ³

A number of safety and health concerns are associated with health care facilities. These include exposure to

In addition to HCWs, health care facilities employ many groups of workers such as electricians, plumbers, housekeepers, and building and ground maintenance crews. Each group has unique workplace safety hazards represented by the seven OSHA standards that receive the most citations. These standards, in the order that they are most frequently cited in health care facilities, are

Reducing workplace risks 

The responsibility of keeping America's workers safe from bloodborne disease has been delegated by OSHA to the employer. Employers are required to reduce and eliminate employee risk through the use of engineering and work-practice controls. Engineering controls involve physically changing the work environment to eliminate exposure to potential hazards. Work-practice controls eliminate exposure to potential hazards by changing the way employees perform their work. If unable to achieve adequate risk reduction through these methods, the employer is required to establish and implement a PPE program.⁹

When properly worn, PPE substantially attenuates environmental risk of exposure to bloodborne pathogens. The OSHA bloodborne pathogens standard requires employers to provide PPE to employees, educate their employees in the proper use of PPE, and monitor employee compliance.¹⁰

A PPE program establishes procedures for selecting and providing PPE and use of PPE by employees when they are engaged in activities where potential risk for exposure to hazards cannot be avoided through other controls. An assessment of the workplace is conducted to determine whether hazards exist or are likely to exist. If so, PPE use is required. When the proper PPE has been selected, each employee must be properly educated about its use. At a minimum, PPE education should address

During the education process, each employee must demonstrate an understanding of the information and the ability to use the PPE properly. Immediate re-education is indicated if the employee cannot demonstrate the required skill or understanding. Employers must maintain written certification of education completed by each affected employee.⁹

Bloodborne pathogens 

Risk is inherent in all occupations to varying degrees. For HCWs, the risk of acquiring a transmissible, incurable, bloodborne disease is perhaps the most frightening. The Centers for Disease Control and Prevention (CDC) has identified HIV, hepatitis B (HBV), and hepatitis C (HCV) as three pathogens requiring surveillance.¹¹

Since the mid 1980s when HIV transmission was first reported in the literature, HCWs have been concerned about the potential risk this virus poses as an occupationally acquired illness. As of December 2001, there had been 57 documented cases of HIV seroconversion among HCWs in the United States.¹² Fortunately, HCWs can take actions to reduce the risk of exposure or, when exposed, to reduce the risk of disease transmission.

Before 1978, HCWs wore gloves only when desired as a measure of cleanliness or a measure of sterility. It was not until the CDC introduced the concept of universal precautions in 1987 as a response to the HIV epidemic that HCWs were required to use PPE in anticipation of potential exposure to blood or other potentially infectious body fluids as a measure of personal safety.¹³

Avoiding occupational blood exposure is the most effective method of preventing transmission of bloodborne disease in the health care setting.¹² The use of PPE reduces contact with infectious materials. Prompt washing of skin surfaces immediately after blood or body fluid exposure reduces the risk of disease transmission. Careful handling and disposal of sharp items during and after use are effective risk-reduction practices.

In 1991, OSHA issued its bloodborne pathogens standard intended to help protect workers from occupational exposure to blood and other potentially infectious material.¹⁰ The regulation requires employers to develop a written exposure control plan designed to reduce or eliminate employee exposure. At a minimum, the plan must address

In 2002, OSHA revised the bloodborne pathogens standard in response to the Needlestick Safety and Prevention Act passed by Congress in October 2000 and signed into law by President Bill Clinton the following month. In addition to previous requirements, employers now also are obligated to select safer needle devices for use in the workplace, annually review advances in technology to reduce risk or injury, involve nonmanagerial personnel in safe device selection, and maintain a log of injuries resulting from contaminated sharps.¹⁴

PPE and health care workers 

The universal precautions introduced by the CDC in 1987 require that HCWs use eye shields, gloves, masks, or gowns, or some combination of these items when appropriate. Health care workers should treat all patients as though they are infected with HIV, HBV, or HCV.¹³ Implementing universal precautions reduces the risk of occupational exposure to bloodborne pathogens; however, universal precautions and PPE are only effective when used properly. Despite the provision of PPE in the workplace and the knowledge that PPE reduces individual risk of exposure, multiple research studies support the conclusion that some HCWs choose not to comply with these regulations and recommendations.¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸ Legally mandating the use of PPE through standards has not improved compliance.¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸

In its bloodborne pathogens standard, OSHA goes one step further than the CDC, not just recommending use of PPE but requiring employers to provide PPE for employees and placing responsibility for employee compliance in the use of PPE on the employer.¹⁰ This responsibility includes educating all employees in the proper use of PPE before they are assigned duties that may result in potential exposure and annually re-educating all employees.¹⁹ In addition, the standard requires that employers clean, launder, and dispose of PPE at no cost to the employee; and, finally, the employer is required to repair or replace PPE to maintain its effectiveness.¹⁰

According to the OSHA standard, employers are accountable for the behaviors of their employees and, as such, are subject to citation and fine during inspection if employees are found to be noncompliant with the use of PPE. In addition to the risk of exposure to occupationally acquired infectious disease, employees are subject to disciplinary actions, up to and including termination, reduction in workers' compensation claims, and loss of future employment opportunities for their failure to properly use PPE.¹⁴

Although employers are held accountable for the actions of their employees, they are not responsible for nonemployee care providers (eg, temporary agency workers, independent physicians, students). The bloodborne pathogens standard applies to all full-time, part-time, temporary, and per diem employees of an organization.¹⁹ The standard does not apply to nonemployee students or to nonemployee physicians who have staff privileges. Finally, although agency workers are covered by the standard, the responsibility for ensuring compliance rests with the agency employer, not the health care facility where the agency worker is assigned. Although not legally required to provide PPE for nonemployee workers, employers have an ethical obligation to provide the same protection to nonemployee care providers working at the facility as they do for employees.

PPE and perioperative services 

Exposure to blood and other potentially infectious substances frequently occurs in ORs; therefore, the availability, use, and proper disposal of PPE is more important there than in other areas of health care. Adopting a standard practice and consistent use of PPE during all patient encounters reduces the risk of exposure to contaminants.¹³ Perioperative service leaders should ensure that eye shields, reinforced gowns, other liquid-repelling garments, and sufficient gloves to allow for double gloving are readily available. Additionally, to help improve compliance, managers should consistently articulate the expectation that all employees will use PPE properly and correct employees who do not. Finally, exposure reporting can be improved if perioperative service leaders provide employees with an easy and quick method of reporting exposures when they occur.¹⁶

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The Rule of Law 

Over the years, various legal actions have established precedence related to the rule of law and workplace safety. Federal law related to workplace safety is established through the Federal Register of the US Department of Labor and is administered through OSHA, which holds employers responsible for creating and maintaining a safe work environment. This responsibility extends to supervising and correcting employee performance regarding the proper use of PPE.¹⁰ If employees are not adhering to established protocols and the employer does not correct performance, the employer, not the employee, can be found in violation of OSHA standards and, thus, fined.

Workplace accidents or injuries are addressed at the state level through a workers' compensation statute. The importance of a workers' compensation statute is that workplace accidents or injuries are taken out of the tort/liability courts. Workers' compensation coverage is an employee's exclusive remedy for workplace injury or occupational illnesses; therefore, an employee cannot sue an employer for a workplace accident except through the workers' compensation statute.

This area of law continues to evolve and has been challenged in several states' courts of appeals. For instance, in Ryan v Clonch Industries, Inc, Ryan, who was rendered permanently blind in one eye after a workplace accident, alleged deliberate intent on the part of his employer.²⁰ The plaintiff was seeking to challenge the immunity afforded Clonch Industries under the state's workers' compensation system. Immunity from corporate liability may be lost only if the employer acted with “deliberate intention.” In order to determine deliberate intention, the courts have held that all of the five following conditions must be present:

In this case, Ryan prevailed. Clonch Industries admitted that it had failed to comply with the mandatory duty to perform a hazard evaluation imposed upon it by OSHA.³ Ryan was able to pursue a liability claim against his employer over and above his state's workers' compensation benefits.

As it relates to PPE, a worker's compensation may be reduced by 25% if the injury is caused when an employee refuses to use a safety appliance or obey a safety rule.²¹ For example, in McKenzie Tank Lines, Inc, v McCauley, the employer contended that it had provided McCauley with PPE to use when loading and unloading potentially harmful substances from his truck and that if McCauley had been wearing it at the time of the accident, he would not have been injured.²² In addition, the employer produced a number of documents attesting to the fact that PPE was purchased and that employees were told how and when to use the PPE, all which occurred before McCauley's injury. Although McCauley testified that he had never been issued safety equipment nor been ordered to wear PPE, an inspection of his truck after the accident revealed a pair of safety glasses behind the driver's seat. In this case, the court found in favor of the employer, McKenzie Tank Lines, Inc.

Exposure to bloodborne pathogens as an occupational injury presents challenging and complex legal issues. Although there have been some court rulings, case law has not yet completely defined the scope of the problem.²³ For the most part, expenses incurred related to testing after exposure to bloodborne pathogens are considered compensable injuries under the workers' compensation act, but claims related to fear of developing disease have had limited success. In Doe v City of Stamford et al, the Connecticut Supreme Court ruled that sustaining actual exposure to life-threatening infectious diseases during the performance of duty is compensable, and the claimant could recover expenses related to testing, even though he had not contracted a disease.²⁴ In McLarney v Community Health Plan, McLarney, a housekeeping worker in a medical office, was injured by a needle while cleaning an examination room.²⁵ She was placed on postexposure prophylaxis against HIV to which she experienced side effects. The plaintiff brought a claim against the medical office for her fear of developing AIDS; her claim was rejected by the courts. She was allowed to proceed with the portion of her claim related to her medical treatment and side effects. In Castro v New York Life Insurance Co, however, the court allowed a housekeeping worker to proceed with her claim related to fear of developing AIDS after injury by a used needle.²⁶

The above cases reflect diverse opinions held by the courts after an injury without subsequent development of disease. In the immediate future, courts will be challenged to further develop the rule of law in workers' compensation cases when employees develop bloodborne illnesses. To date, court opinions vary widely. The issue of whether a worker's bloodborne disease is compensable is complex.²³ It is difficult to prove or disprove that a bloodborne disease was work related (ie, compensable) versus socially acquired (ie, noncompensable). Health care workers document and report fewer than 60% of needlestick injuries or other blood exposures.¹⁶ In addition, lawsuits must be filed within prescribed time limits; this frequently is not possible when an employee's disease status may not be known for years after infection.

During the next decade, the courts will be challenged to respond to these difficult and complex issues. As they do, education professionals will be well served to stay current with legal opinions and court views. Education professionals, however, are protected from personal liability through the exclusive remedy portion of the workers' compensation act. An employee could attempt to raise a defense to any reduction in benefits arising through the improper use or failure to wear PPE by claiming inadequate education; however, the employee could not sue the employer or the educator for improper training.

In general, worker's compensation claims are the only avenue available for injured employees to seek remedies from their employers.²³ Despite protections provided through the exclusive remedy portion of the OSH Act, it remains incumbent upon employers to ensure that employees receive appropriate and effective education. Educators using effective adult learning principles are empowered to change behavior and protect human lives through education while protecting the employer from legal action. Ineffective or incomplete education in the use of PPE has significant consequences in the prevention of disease.

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Implications 

Employers must remain current with OSHA standards as a means of improving the safety of the US workplace. Employers of HCWs in particular are challenged to promote and facilitate the reporting of needle-stick injuries and exposure to blood or other potentially infectious material by their employees. Health care workers who have sustained needle-stick injuries demonstrate a very poor compliance rate for reporting exposures, even when the exposure involves a high-risk patient.²⁷ Accurate reporting allows safety mechanisms to be developed that lower risk and reduce exposure, further augmenting HCW occupational safety. Keeping workers safe, specifically as it relates to bloodborne pathogens, is the employers' burden.

Before implementing any educational programs to meet OSHA requirements, educators must ensure that

Educators are required to update their educational content annually, emphasizing new or updated information.¹⁹ In so doing, responsible educators ensure that employees are provided necessary information to protect themselves in the workplace and thus also protect the employer from liability.

After meeting OSHA education requirements, educators must ensure that their records are complete and retrievable. During an OSHA inspection, educators must be able to provide randomly requested employee education records.⁸ Employee behavioral change after education should be evaluated in the workplace via random rounds, workplace audits, or quality improvement inspections. Determining whether education resulted in a change in workplace practice is a good measure of assessing educational effectiveness.²⁸ Those employees who are observed not to be adhering to OSHA requirements should be counseled; enrolled in re-education; and, if necessary, referred to a managerial staff member for corrective action. Educators also should publicly acknowledge employees who properly observe OSHA requirements. Timely and positive feedback for desired performance helps to reinforce the behavior and promote reoccurrence.

Employees, like employers, have a duty to remain current with workplace safety requirements. Correct and consistent use of PPE as required in OSHA's bloodborne pathogen standard has perhaps the most significant implications for the individual employee. Remaining safe from bloodborne pathogens affects both an employee's personal and professional life. Employees are encouraged to use the PPE provided by their employers and to ensure timely reporting of exposure should an incident occur. Proper reporting of exposure allows for the administration of prophylaxis when possible, and may be useful in supporting a workers' compensation claim in the future, if necessary.²⁷

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Examination 

Improving Compliance With Occupational Safety and Health Administration Standards 

Purpose/Goal 

To educate perioperative nurses about how compliance with Occupational Safety and Health Administration (OSHA) standards improves the safety of health care settings.

Behavioral Objectives 

After reading and studying the article on OSHA, nurses will be able to

Questions 

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Answer Sheet 

Improving Compliance With Occupational Safety and Health Administration Standards 

Event #08008

Session #8509

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Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

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Program offered February 2008

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A score of 70% correct on the examination is required for credit.

Participants receive feedback on incorrect answers.

Each applicant who successfully completes this program will receive a certificate of completion.

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Learner Evaluation 

Improving Compliance With Occupational Safety and Health Administration Standards 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about how compliance with Occupational Safety and Health Administration (OSHA) standards improves the safety of health care settings.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ________________________________________________________________________________________________________

Author names and addresses: _____________________________________________________________________________________________________________________________________________________________________________

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References 

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5. Pepper TG . Understanding OSHA: a look at the agency's complex legal and political environment . Prof Saf . February 2001;14–16
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9. Personal protective equipment. US Department of Labor Occupational Safety and Health Administration . http://www.osha.gov/Publications/osha3151.pdf Accessed December 6, 2007.
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10. Occupational safety and health standards: bloodborne pathogens. 56(235) Fed Regist. (December 6, 1991) 64004 (codified at 29 CFR §1910.1030).
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11. Centers for Disease Control and Prevention  . Public Health Service guidelines for the management of health care worker exposures to HIV and recommendations for postexposure prophylaxis . MMWR . 1998;47(RR-7):1–33
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12. Preventing occupational HIV transmission to healthcare personnel. Centers for Disease Control and Prevention . http://www.cdc.gov/hiv/resources/factsheets/PDF/hcwprev.pdf Accessed December 6, 2007.
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13. Universal precautions for prevention of transmission of HIV and other bloodborne infections. Centers for Disease Control and Prevention . http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html Accessed December 6, 2007.
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14. Taylor DL . Bloodborne pathogen exposure in the OR—what research has taught us and where we need to go . AORN J . 2006;83(4):834–846
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15. Akduman D , Kim LE , Parks RL , et al.   Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery . Infect Control Hosp Epidemiol . 1991;20(2):110–114
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16. Cutter J , Jordan S . Uptake of guidelines to avoid and report exposure to blood and body fluids . J Ad Nurs . 2004;46(4):441–452
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17. Gershon RR , Vlahov D , Felknor SA , et al.   Compliance with universal precautions among health care workers at three regional hospitals . Am J Infect Control . 1995;23(4):225–236
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18. Nelsing S , Nielsen TL , Nielsen JO . Noncompliance with universal precautions and the associated risk of mucocutaneous blood exposure among Danish physicians . Infect Control Hosp Epidemiol . 1997;18(10):692–698
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19. Gile TJ . The OSHA lowdown on occupational exposure to bloodborne pathogens. Medical Laboratory Observer . http://www.mlo-online.com/ce/pdfs/june01.pdf Accessed December 6, 2007.
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20. Ryan v Clonch Industries, Inc, 3069316 SE2d WL (WVa 2006).
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21. Workers' Compensation Law, FL Stat, ch 31, § 440 et seq (2001).
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22. McKenzie Tank Lines, Inc v McCauley, 418 So2d 1177 (Fl Ct App 1982).
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23. Ross CS . The evolving medical, social, and legal issues of occupational exposure to bloodborne pathogens . Clin Occup Env Med . 2002;2(3):575–592
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24. Doe v City of Stamford et al, 241 A2d52 692, 699 (Conn 1997).
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25. McLarney v Community Health Plan, 81958 3d (NY App Div 1998).
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26. Castro v New York Life Insurance Co, 588 NYS2d 880 (NY Sup Ct 1996).
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27. Makary MA , Al-Attar A , Holzmueller CG , et al.   Needlestick injuries among surgeons in training . N Engl J Med . 2007;356(26):2693–2699
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