Effective Date: 
Mon, 04/01/2002
Tue, 08/31/2021
Mon, 08/12/2019


2. The Hazardous Waste Management Policy includes guidelines for the proper handling of contaminated trash, sharps, and lab specimens in the clinic area and the disposal of other hazardous waste.
3. All personnel use proper practices in the handling and disposition of infectious waste to effectively control the spread of infection.
4. Infectious waste includes, but is not limited to, the following:
a. Syringes, needles, and I.V. sets
b. Surgical blades
c. Dressings from draining wounds
d. Any material which comes in contact with a draining wound
e. Human tissue/specimen not sent for pathological evaluation
f. Blood elements, excreta, and secretions
g. Disposable equipment/supplies used for the care of the patient
h. Any other material presenting a threat of infection
Staff are trained on proper identification, management, handling, transport, and disposal of all hazardous materials and wastes.
1. Hazardous waste trash receptacles are labeled as such and lined with red bags. Only trash that is saturated with blood is considered hazardous waste for the purpose of utilizing this disposal system.
2. Nursing personnel is responsible (not custodial staff) for the emptying of biohazardous wastes - to be disposed of daily if there are any contents.
3. Staff member wears gloves and other items of PPE (i.e., lab coat or gown) while handling biohazardous waste.
4. The red bag is removed from the can and closed securely.
5. The red bag is transported to the laboratory and put in the biohazardous waste cans for pickup.
6. A fresh bag is readied in the hazardous waste can for subsequent use.
1. All employees handling bodily fluids or lab specimens wear personal protective equipment (PPE) as indicated by the anticipated risk of performing the task. Gloves, gowns, masks, leg coverings and booties or full suit etc. are readily available in convenient locations for the handling of specimens.
2. Clinical or utility areas where lab specimens are processed (POC testing only) are clearly designated regarding clean or dirty for the purposes of defining where various tasks are performed.
3. Hand hygiene is performed at a station separate from the dirty utility sink area.
4. All specimens are sent to the lab in transport trays for processing and/or disposal.
5. Transport trays are cleaned by laboratory staff after each use.
1. Puncture-proof sharps containers are located throughout the patient care areas, secured in a manner to prevent tampering.
2. These specialty collection units are for the proper disposal of needles, syringes, scalpels, and any other sharps items that fit easily into the puncture-proof sharps collection boxes.
3. The sharps containers are removed when filled to the "fill line" by the nursing personnel and are replaced with new containers.
4. The full sharps containers are stored with the hazardous waste bags in the designated, closed container located near the lab.


1. Pharmaceutical waste must be incinerated. The SHC uses a third party reverse distributor for returning unused and expired medications as much as possible.

2. In the SHC, all partially used non-hazardous, pharmaceutical waste must be collected and stored in an alternate, approved sharps container, labeled "incineration only". The pharmaceutical sharps container is segregated and placed in areas in the SHC where pharmaceuticals are prepared and used for patient administration.

3. Only partially used vials, syringes and ampules of pharmaceutical waste need to be deposited in the pharmaceutical waste container. Empty vials, glass or otherwise, and without PHI, may be thrown into regular trash. Empty is commonly accepted as less than 3% of original total volume and there are no pourable contents. Broken glass vials and ampules need to be placed in a regular sharps container. Non-pharmaceuticals, including sodium bicarbonate, sodium chloride and water for injection may also be thrown into regular trash. Examples of pharmaceuticals to be placed into the pharmaceutical waste containers include the following: lidocaine and other injectable anesthetics, injectable ketorolac, injectable sumatriptan, injectable steroids, injectable ondansetron, injectable promethazine and ceftriaxone.  It also includes epinephrine. Other injectable hazardous drugs (HD) including medroxyprogesterone (Dep-Provera), testosterone and estrogen vials, empty or partially full, must also be deposited into pharmaceutical sharps containers.

4. A full pharmaceutical waste container may be stored for up to 90 days and a partially full container must be disposed of annually. The containers have a sticker that must be dated when the container is operational. These full pharmaceutical waste containers will be collected and stored separately from the biohazardous waste, and our biohazardous waste hauler will collect, document via manifest, and haul, both types of sharps containers plus biohazards.

5. Patients and visitors can dispose of expired medications and other pharmaceutical waste in the "waste" kiosk at the Pharmacy. Vitamins, minerals, fiber supplements, etc., can be disposed of in the regular trash.

E. Other Hazardous Waste

All other hazardous waste that must be collected is done via the Environmental Health and Safety (EH&S) department using their On Line Waste Tag system - WASTe (includes Trichloroacetic Acid, thimerosal and reagents etc.).