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° ® EXHIBIT 5. <br /> PrePdi ad by: Brenda . . Flynn, M.D. Section: 1.315 <br /> Adopted: 1/11/83 <br /> Supersedes: N/A <br /> POLICY REVIEW <br /> Reviewed <br /> Reviewed <br /> Reviewed <br /> Reviewed <br /> [Revised 4/06/88 BF 5/08/91 BF <br /> NECROPSY (AUTOPSY) & SURGICAL PATHOLOGY SAFETY POLICY <br /> POLICY <br /> Barrier (Universal) precautions, in conformance with hospital policy, will be <br /> the minimum guidelines for conducting procedures associated with necropsy <br /> (autopsy) and surgical pathology. More stringent techniques representing good <br /> laboratory practice may be adopted as necessary based upon a review of the spe- <br /> cific clinical information. <br /> PURPOSE <br /> To ensure that laboratory workers engaged or assisting in necropsy (autopsy) or <br /> surgical pathology procedures handle human tissues or associated body fluids in <br /> a manner, t at minimizes the risk of infection, and to ensure that human <br /> anatomical/pathological wastes are appropriately identified, sorted and safely <br /> and efficiently disposed of in accordance with federal , state, local regulations <br /> and other external agency guidelines. Anatomical/pathological wastes include <br /> tissues, organs, body parts and fluids that are removed during surgery, autopsy <br /> or other medical procedure, and specimens of body fluids and their containers. <br /> PROCEDURE <br /> A. NECROPSY (All cases to be considered potentially infectious) <br /> NOTE: Appropriate bedside preparation in accordance with Nursing Services <br /> Policies. <br /> 1. Barrier Precautions: <br /> The following protective devices are required for persons participating <br /> in the autopsy: <br /> a. Cap/hood that completely covers the hair. <br /> b. Facial barriers such as goggles and mask or plastic face shield <br /> that completely covers the face and neck areas. <br /> c. Clothing that provides coverage from the wrists to neck and <br /> ankles. <br /> d. Water-impervious gown. <br /> e. Double gloves. <br /> f. Water-impermeable shoe covers. <br /> 2. Autopsy Procedures must: <br /> a. Minimize production of droplets and aerosols. <br /> Page 1 of 5 <br />