AJN Article - December 2003: Providing a Framework for Addressing Workplace Hazards

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Health & Safety

American Journal of Nursing - December, 2003 - Volume 103, Issue 12

'Hierarchy of Controls'
Providing a framework for addressing workplace hazards.

By A.B. (Butch) de Castro, PhD, MSN-MPH, RN

Occupational safety and health professionals, including occupational health nurses, occupational health physicians, industrial hygienists, and safety engineers, use a framework called the “hierarchy of controls” to select ways of dealing with workplace hazards. The hierarchy of controls systematically identifies hazards and prioritizes intervention strategies. It is based on the premise that the best way to control a hazard is to remove it from the workplace, rather than relying on workers to reduce exposure. Additional means can be used but offer less protection.

The following control measures are listed from most effective to least effective: elimination, substitution, engineering controls, administrative controls, work practice controls, and personal protective equipment.

  • Elimination—complete removal of a hazard from the work area. An example is when hospitals go “latex free” by not purchasing or stocking latex products such as gloves and tubing, thus doing away with the risk that employees will develop an allergy or have an allergic reaction to latex materials. Elimination is the method preferred in controlling hazards and should be selected whenever possible.

  • Substitution—replacing a conventional material or process with a less harmful alterative. Glutaraldehyde, typically used as a cold sterilant to disinfect heat-sensitive equipment such as endoscopes, can cause dermatitis. Less toxic brands are equally effective and reduce the potential for adverse effects.

  • Engineering controls—removing or isolating a hazard through technology. This measure focuses on the source of the hazard or the pathway of transmission. For example, using a ceiling-mounted system for lifting patients out of bed and into a chair is an engineering control. The equipment, rather than the nurse, bears the burden of lifting.

  • Administrative controls—policies aimed at limiting worker exposure to a hazard, typically accomplished through work assignments. For example, to prevent a patient from assaulting a nurse, staff members may work in pairs when providing care to or transporting a patient on a psychiatric unit. The presence of multiple staff members may discourage patients from attacking.

  • Work practice controls—reduce exposure to occupational hazards through the behavior of workers. Re­capping used or contaminated needles violates the Occupa­tional Safety and Health Administration’s bloodborne pathogens standard because it places the nurse at risk for a sharps injury. Compliance with this regulation relies on the health care worker’s not engaging in this practice.

  • Personal protective equipment (PPE)—the least effective measure of control in the hierarchy. PPE includes clothing and equipment designed to be a barrier between worker and hazard. This measure should be the last option when trying to reduce worker exposure, since it doesn’t control the hazard itself. Examples of PPE are the gowns, gloves, masks, and eye shields used when caring for a patient diagnosed with severe acute respiratory syndrome. If the PPE fails or is in poor condition or of poor quality, workers may be exposed.

    By understanding and using the hierarchy of controls, hospitals can prevent or minimize exposure to occupational hazards. It is critical to strive for the most effective measure possible and when selecting control measures, use a combination of methods. Nurses should be familiar with hazard control measures within their workplaces and use the hierarchy of controls framework to assess whether the appropriate health and safety measures are being taken.


    A.B. (Butch) de Castro is the senior staff specialist for the ANA Center for Occupational Health and Safety.

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