Any Facility that provides patient treatment with a Class III or Class IV laser system is required by National Standards to designate an individual as the facility’s Laser Safety Officer. The role is defined as the person responsible for the Laser Safety Program. The expectation is that the individual performing the duties of the Laser Safety Officer (LSO) has the training and experience to administer and oversee the Program with ongoing support from other team members within the organization.
Individuals who perform the duties of the LSO vary from facility to facility; however, the person who usually volunteers (or is “voluntold”) is familiar with laser applications that are performed within the facility. The LSO is typically a secondary role that is taken on by the Department Manager, a Nurse, a Clinical Engineer, a Scrub Tech, an Office Manager, or an Aesthetician. The role of a LSO within a healthcare facility can be overwhelming in the beginning, however, in time, the LSO becomes a trusted partner working with the Surgeons and other Staff Members in establishing a safe laser environment meeting the needs of its patients and community.
If the facility does not have a Laser Safety Program already established and in place, the designated LSO will have to help in developing a Laser Safety Committee who will be responsible for writing the Laser Safety Policy & Procedure Manual along with maintaining an “Active” Laser Safety Program. While the Policy and Procedures Manual is important, I like to educate students that attend my course that the Policy & Procedures Manual needs to be based on actual practices that are being performed on a daily basis at the facility. The Policy & Procedure Manual is only as good as the daily practices that are implemented to keep the patients & staff safe. So, not every Policy & Procedure Manual will look the same at every facility.
One of the many questions I hear from newly appointed Laser Safety Officers is, “Now, what?”
To get your Laser Program going in the right direction, I recommend the following 10 Step Process:
1.Register and attend a recognized Laser Safety Officer Training Program-If you have completed this course in the past but it has been more than 3yrs, it is recommended that you retake the course.
2.Purchase the ANSI Z136.3 (2011) Safe Use of Lasers in Healthcare-This publication is recognized as the definitive document on Laser Safety in all healthcare environments. It provides guidelines for safe use of lasers for medicine, diagnostics, cosmetic, preventive and therapeutic applications. If your facility does not have this publication on hand or if the one you have is out of date, you will need to purchase one and use it as a reference in establishing your Laser Program Policy & Procedures.
3.Research and obtain any and all information regarding State Regulatory Programs-Some States have additional regulations that require registration of lasers, appointment of a Laser Safety Officer, licensing of Laser Operators, or more stringent regulations regarding the reporting of incidents. Check to ensure that your Laser Program is in compliance with State regulations and be sure to incorporate the requirements into your program. Below is a list of States that currently have a “formal” Regulatory Agency responsible for establishing non-ionizing radiation regulations:
|SUMMARY OF CURRENT STATE LASER REGULATIONS|
|Alaska||Environmental Conservation||Title 18, Article 7|
|Arizona†||Radiation Regulatory Agency||Title 12, Chapter 1, Article 14|
|Arkansas||Division of Radiation Control Emergency Management||Act 460|
|Florida†||Department of Health & Rehabilitative Services||Non-Ionizing Chapter: 10D-89|
|Georgia||Department of Public Health||Chapter: 290-5-27|
|Illinois||Department of Nuclear Safety||Chapter: 111 ½|
|Massachusetts||Department of Public Health||105 CMR 21|
|Montana||Health & Environmental Services||92-003|
|New York||Department of Labor||Code Rule 50|
|Pennsylvania||Environmental Resources||Chapter: 203, Title 25|
|Texas||Department of Health||Radiation Control Act Parts 50, 60, 70|
|Washington||Labor & Industry||Chapter 296-62-WAC|
4.Establish a Laser Safety Committee-Developing a Laser Program is a team effort, your facility should provide you with adequate resources to develop the program, your goal as the LSO is to implement and enforce the program. A Laser Committee needs to be formed to advise on the development of Laser Safety Policy & Procedures. This should be a multidisciplinary group of professionals within the organization who are involved with the management of the facility as well as members who work with the laser(s) routinely. Recommended members of the Laser Committee include: Surgeons, Director Safety Department, Medical Director, OR Staff Member, Hospital Administration, Department Director, Employee Health, Member of Medical Staff Office, Risk Management, Purchasing, Clinical Engineering, or any other key staff member involved with the application of laser technologies. Meetings should be held as required to accomplish the goal of establishing the Policy and Procedures and then Annually (at a minimum) to review the ongoing performance of the Laser Safety Program to make recommended changes to the Program as needed.
Most regulatory agencies want to see that your Laser Safety Program is “active”. The only way to prove this is to provide “Laser Committee Meeting Minutes” that detail topics of discussion and corrective actions taken by the Committee. Additionally, the LSO shall be performing a Laser Safety Audit of the Laser Program on a routine basis and reporting the outcome of the Audit(s) to the Laser Committee.
5.Designate a Deputy LSO-Larger facilities should consider designating a Deputy LSO. Unless you plan to never take a day off you will want to designate someone to oversee the program and/or procedures when you are unavailable. Although it is not required, LSO training is highly recommended for your designated deputy. LSO Deputies should show competency of Basic Laser Safety, Laser Operation, and be well versed in the Laser Policy & Procedures. One of the most important aspects of the position is to know what to do in the case of an incident with the laser to make sure all required actions are carried out in a timely manner.
6.Develop Laser Safety Policy and Procedure Manual-Develop your Laser Safety Policy and Procedures. There is a lot of “gray” in this statement due to the fact that you can formulate the Policy and Procedures to best meet your facilities needs. At a minimum, your Laser Safety Policy and Procedure Manual must incorporate all statements from the ANSI publication Z136.3 that are detailed as “SHALL” statements. ANSI utilizes “SHALL” as a required action and “SHOULD” as an advisory action. Beyond the evaluation of these statements, you must review State Regulations regarding Non-Ionizing Radiation and develop the Policy and Procedures to provide a safe environment for laser applications.
Again, the Policy & Procedures manual needs to be based on actual practices that are being performed on a daily basis at the facility. The Policy & Procedure Manual is only as good as the daily practices that are implemented to keep the patient and staff safe. You want to take the approach that if you end up in court for some reason, your Laser P&P “reflects” the actual actions that are taken during every laser procedure. Every facility will have a different Laser P&P based on the daily practices, the example that we provide is a guideline of items that may or may not apply to your facility.Sample form: www.ReliableLaser.com/LSForms/P&P_OUTLINE
7.Develop Laser Safety Audit Form-In the process of developing your Policy and Procedure Manual, you will need to establish a way to “monitor” your Laser Safety Program on a routine basis. This concept requires the development of a Laser Safety Audit Form for use by the LSO (or an individual authorized by the LSO) to make random inspections of the Laser Safety Program. These inspections should be performed on an Annual basis (minimum). I highly recommend more frequent evaluation of your Laser Safety Program to ensure compliance with your Laser Policy and Procedures. This is another way to show your Laser Program is “active” if your program is audited by an outside agency.
Sample form: www.ReliableLaser.com/LSForms/AUDIT
8.Develop Personal Protective Equipment Inspection Form-The use of personal protective equipment for your employees and patient will need to be incorporated in your Laser Program. To ensure this equipment is in good condition, Annual or Semiannual inspections need to be performed. Personal Protective Equipment should include, but is not limited to, staff & patient eyewear, window covers, and laser signs. An Inspection Form needs to be developed and utilized.
9.Develop Laser Procedure Log Form-A Laser Log should be created that details the procedures taken to ensure a safe lasing environment as well as the parameters of laser application during treatment. Forms should be specific to the laser system and/or the laser procedures that are performed. It is difficult to have one (1) form meet the needs of proper documentation for different types of laser systems or clinical applications when more than one laser is utilized at a facility. The sample form that is provided should be modified to meet your specific needs.
Sample Form: www.ReliableLaser.com/LSForms/LOG
These forms should be reviewed by the LSO and/or the Laser Committee as an additional tool in evaluating quality and consistency of the actions being performed on a daily basis during each Laser Procedure.
10.Ensure facility Incident Report incorporates fields for Laser Safety issues-All laser incidents should be documented and reported, regardless of how minimal. Most organizations have their own Incident Report guidelines, therefore, there is no sample form provided by Reliable Laser Solutions.
If your organization does not have a guideline for incident reporting in place, reference the ANSI publication Z136.3 and your State regulations.
Tips to keep your program organized:
Create a Laser Program Binder with tabs for each of the recommended steps we provided above.
Create a Binder for each laser to keep important documentation together in one place.
If you have multiple lasers at your facility, to keep eyewear coordinated for each laser choose a different frame for each laser type.
Designate a Deputy LSO to oversee the program in the event the Lead LSO is unavailable, have them complete a LSO training course as well.
Register to take the Board of Laser Safety LSO Certification Exam. Although this certification is not required by any National or State agency, this certification indicates that the individual has specific knowledge, skills, or abilities in the view of a certifying body. Our course fulfills the requirement of one (1) CE Credit for ongoing education requirements set by the Board of Laser Safety.
Other forms that may be useful in developing your Laser Safety Program:
OR Laser Procedures Checklist – a list of common things to ensure the OR is ready for every Laser Procedure.
Eyewear Inspection Checklist: NOTE: All Laser Protective Eyewear must be labeled by the manufacturer with the Wavelength and Optical Density (OD) to meet ANSI Standards. Laser Safety Eyewear should be inspected during every laser procedure. However, to ensure your Laser Safety Eyewear is in good condition and meeting all requirements set forth by ANSI, you should take the added step of inspecting all of your eyewear on a routine basis. Annual inspection would be a minimum recommendation. You should develop an inspection form that allows you to log the results of your inspection for every pair of Laser Protective Eyewear. Many of our students use a label maker to label each pair of eyewear to help keep track (i.e., C1, C2, C3… for CO2 Eyewear; H1, H2, H3… for Holmium Eyewear; etc.).
Laser Assistant Competency Checklist – Ongoing Laser Training and documentation of all Laser Related Educational Activities is also a great way to detail actions that are being taken on a routine basis to improve the Laser Safety Program.
Laser Maintenance Log – depending on your facility and the amount of use, semi or annual (minimum recommendation) maintenance of the laser is required. Track Maintenance with this log.
Sample Form: www.ReliableLaser.com/LSForms/LASER-PM