Skip to main content

Full text of "DTIC ADA400373: How to Prevent Needlestick Injuries: Answers to Some Important Questions"

See other formats

H ow to Prevent 

Needlestick Injuries 

A nswers to Some 
Important Q uestions 

Report Documentation Page 

Report Date Report Type 

00001999 N/A 

Dates Covered (from... to) 

Title and Subtitle 

Contract Number 

How to Prevent Needlestick Injuries: Answers to Some 
Important Questions 

Grant Number 

Program Element Number 


Project Number 

Task Number 

Work Unit Number 

Performing Organization Name(s) and Address(es) 

U.S. Department of Labor Occupational Safety & Health 
Administration 200 Constitution Avenue Washington, 

DC 20210 

Performing Organization Report Number 

OSHA 3161 

Sponsoring/Monitoring Agency Name(s) and 

Sponsor/Monitor’s Acronym(s) 


Sponsor/Monitor’s Report Number(s) 

Distribution/Availability Statement 

Approved for public release, distribution unlimited 

Supplementary Notes 

The original document contains color images. 


As an employer of health care workers, you want and need to provide a safe and healthful workplace for 
your employees. In 1991, OSHA published the Bloodborne Pathogens Standard, Title 29 Code of Federal 
Regulations, Part 1910.1030, to protect workers from exposures to bloodborne illnesses. Because 
needlestick injuries are a major cause of these exposures in the health care setting, it is important to 
recognize that there are work practices and engineering controls to help reduce these exposures and 
injuries. This brochure looks at the issue of safer needle devices and how they can help employers like 
you create a safer workplace to protect your workers. 

Subject Terms 

Report Classification 


Classification of this page 


Classification of Abstract 


Limitation of Abstract 



As an employer of health care workers, you want 
and need to provide a safe and healthful workplace 
for your employees. In 1991, OSHA published the 
Bloodborne Pathogens Standard, Title 29 Code of 
Federal Regulations, Part 1910.1030, to protect work¬ 
ers from exposures to bloodborne illnesses. Because 
needlestick injuries are a major cause of these 
exposures in the health care setting, it is important 
to recognize that there are work practices and 
engineering controls to help reduce these exposures 
and injuries. This brochure looks at the issue of 
safer needle devices and how they can help em¬ 
ployers like you create a safer workplace to protect 
your workers. 

W hy Do I N eed If you're an employer of 
to Worry A bout health care workers who are 
M ppH I pd-1 r k- c? potentially exposed to blood 

and contaminated needles, 
you should know that there 
are an estimated 800,000 needlesticks each year in 
the U.S. About 2 percent, or 16,000, of these are 
likely to be contaminated with the Human Immu¬ 
nodeficiency Virus (HIV). Needlestick injuries 
account for up to 80 percent of accidental exposures 
to blood. Nurses in hospitals are the most fre¬ 
quently injured. 

When M ight 
My Employees 
Be Injured 
By a 


Needlestick injuries may 
occur when employees 
dispose of needles, collect 
and dispose of materials 
used during patient care 
procedures, administer 
injections, draw blood, or handle trash or dirty 
linens where needles have been inappropriately 

Isn't There Just 
a Small Chance 
of Such an 

Data from 63 hospitals show 
that the overall rate of such 
injuries is 27 per 100 occu¬ 
pied beds annually. Nurses 
had the most frequent 
exposures (49.7 percent); physicians ranked second 
(12.6 percent); nursing assistants accounted 
for 5.3 percent, and housekeepers, 5.1 percent. 1 
Hollow-bore needles are the cause of injury 
in 68.5 percent of all cases. 

1 G. Ippolito; V. Puro; N. Petrosillo; G. Pugliese; B.Wispelwey; P.M. Tereskers; 
N. Bentley; and J. Jagger, Prevention, Management & Chemoprophylaxis of 
Occupational Exposure to HIV (Charlottesville, VA: Advances in Exposure 
Prevention, International Health Care Worker Safety Center, 1997). 

What Can 
Happen from 
a Needlestick? 

More than 20 pathogens 
have been reportedly trans¬ 
mitted from needlesticks. 2 
The most serious are the 
transmission of Hepatitis C 
(HCV), Hepatitis B (HBV), and HIV. In fact, the risk 
of acquiring HBV or HCV from a contaminated 
needlestick is greater than for HIV. 

Why Is the Risk 
G reater from 
Hepatitis B and C 
Than from HIV? 

The risk of acquiring an 
infection has to do with the 
prevalence of these diseases 
in the patient population 
at large. For example, an 
estimated 1.25 million 
people in the U.S. are chronically infected with 
HBV and 6,000 die each year from HBV-related 
liver disease. HCV also is a major cause of chronic 
liver disease worldwide. In 1997, there were an 
estimated 4 million people in the U.S. infected with 
HCV. 3 As many as 85 percent of all HCV-infected 
persons develop chronic hepatitis and are at 
increased risk for cirrhosis and primary hepatocel¬ 
lular carcinoma. 4 Liver failure from Hepatitis C is 
the leading reason for liver transplants in the U.S. 

So, DO I Still 
N eed to Worry 
A bout HIV 
for Employees? 

Yes. The total number of 
occupationally acquired HIV 
infections in health care 
workers continues to in¬ 
crease each year. Of the 52 
such cases documented 
during 1996,45 were from 
needlesticks or cuts. 5 

Make sure that employees 
use universal precautions, 
engineering and work 
practice controls, and per¬ 
sonal protective equipment 
to reduce their exposure to 
bloodborne pathogens, as required by OSHA's 
Bloodborne Pathogens Standard. 6 

How Can I 
Protect Employees 
A gainst Potential 

2 L.A. Chiarello, Deborah Nagin, and Franklin Laufer, Pilot Study of 
Needlestick Prevention Devices, Report to the Legislature, New York State 
Department of Health, March 1992, p.16. 

3 U.S. Department of Health and Human Services, National Institutes of 
Health, Consensus Development Statement: Management of Hepatitis C. 
Available online at 

4 Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report 
88(2), 1996. 

5 Centers for Disease Control and Prevention, Division of HIV/AIDS 
Prevention, National Center for HIV, STD, and TB Prevention, HIV/AIDS 

Report 8(2): Atlanta, GA 1996. 

6 Title 29 Code of Federal Regulations, Part 1910.1030. 

C an't N eed Ies You're correct. Most 
Penetrate M OSt personal protective equip- 

Personal Protective ment can be easily pen- 
r . , 0 etrated by needles. Most 

Equipment? needlestick injuries, how- 

ever, result from unsafe 

needle devices rather than carelessness by health 
care workers. Safer needle devices have been 
shown to significantly reduce needlesticks and 
exposures to potentially fatal bloodborne illnesses. 7 

What's a Safer 
N eedle Device? 

A safer needle device has 
built-in safety controls to 
reduce needlestick injuries 
before, during, or after use 
and to make needlesticks 
less likely. 

Will These 
Devices Prevent 
N eed lestick 

Not all needlestick injuries 
are preventable, but the 
number can be reduced by 
using devices containing 
needles with built-in safety 
features or other devices that eliminate the use of 
needles altogether. Using needleless IV connectors, 
self re-sheathing needles, or blunted surgical 
needles, for example, can help reduce the risk of 
injury. In fact, almost 83 percent of injuries from 
hollow bore needles are potentially preventable. 8 

H 0 W Do T h ese In general, properly 
D ev i ces W 0 r k ? designed devices should 

(1) provide a barrier between 
the hands and the needle 
after use; (2) allow or require 
the worker's hands to remain behind the needle 
at all times; (3) have safety features integral to the 
device itself rather than as accessories; (4) be in 
effect before disassembly and remain in effect 
after disposal to protect downstream workers; 

(5) be simple and easy to operate, with little or no 
training; and (6) not interfere with the delivery 
of patient care. 

A re There Specific Yes, that would be helpful. 
Safety Featu res For example, it is good to 
I |\| opH to Know know whether the feature is 
A . . 9 active or passive or whether 

the engineering control is 

part of the device. Types of safety features include 
the following: 

7 Centers for Disease Control and Prevention, Division of HIV / 
AIDS Prevention, National Center for HIV, STD, and TB 
Prevention, HIV/AIDS Surveillance Report, 9(1): Atlanta, GA, 

8 Ippolito, et al, 1997. 

• Passive safety features remain in effect before, 
during, and after use; workers do not have to 
activate them. Passive features enhance the 
safety design and are more likely to have a 
greater impact on prevention. (See Figure 1.) 

• Active devices require the worker to activate 
the safety mechanism. Failure to do so leaves 
the worker unprotected. Proper use by health 
care workers is the primary factor in the 
effectiveness of these devices. (See Figure 2.) 

• An integrated safety design means that the 
safety feature is built in as an integral part of the 
device and cannot be removed. This design 
feature is usually preferred. (See Figure 1.) 

• An accessory safety device is a safety feature 
that is external to the device and must be 
carried to, or be temporarily or permanently 
fixed to, the point of use. This design also is 
dependent on employee compliance, and 
according to some researchers, is less desirable. 

These connectors use devices other than needles to connect one IV 
to another. Examples of needleless connectors include 3-way 
stopcocks and plunger-type systems. An example of the plunger- 
type system is shown here. These devices are passive and integral 
to tlte system. 

Before us< 


- ■ pi 

| | i : 

After use 

u l 

o=0l mi m ■ 1 1 l:(- 

Figure 2. Self-Resheathing N eedle 

Initially, the sleeve is located over the barrel of the syringe with 
the needle exposed for use. After the device is used, the user 
slides the sleeve fonvard over the needle where it locks in place 
and provides a guard around the used needle. 

Does 0 SH A No. OSHA does not require 

Requirethe employers to institute 

U se Of Specific specific devices, but it does 
Devi ces? require that employers 

evaluate the effectiveness of 
existing controls and review 
the feasibility of instituting more advanced engi¬ 
neering controls. Further, OSHA's Bloodborne 
Pathogens Standard 9 requires that employers 
establish a written exposure control plan as well as 
engineering and work practice controls to eliminate 
or minimize employee exposure. Additionally, 
employers are required to provide post-exposure 
follow-up if an employee sustains a needle punc¬ 
ture and to record the injury on the OSHA 200 log 
in some cases. 

What Steps Do 
I N eed to Take 
to H ave a 
Program and to 
Implement Safer 
Needle Devices? 

As an employer of health 
care workers, you have the 
flexibility to develop indi¬ 
vidual worksite-specific 
needlestick prevention 
programs to protect employ¬ 
ees. Such a program would 
mean that you have a 
mechanism in place to select 

and evaluate safer medical 
devices in a systematic manner. In evaluating safer 
needlestick devices, ideally you should evaluate 
your workplace and base your choices for these 
types of products on the following: 

• The needs of the primary users. 

• The need of the patients who must continue to 
receive safe, efficient, and comfortable care. 
(Workers are likely to reject products that they 
think will interfere with patient care in any 

In addition, a comprehensive needlestick preven¬ 
tion program might include the following: 

• Creating a multidisciplinary team to investigate 
and assess needlestick incidents. 

• Defining prevention priorities on the basis 
of collection and analysis of an institution's 
injury data. 

• Developing design and performance criteria 
for product selection according to needs 

for patient care and health care worker safety. 

• Planning and implementing an evaluation 
of products in clinical settings. 10 

To evaluate and select appropriate safer needle 
devices, you also should review available 
needlestick injury data including the personnel 
involved, the devices used, and the circumstances 
and frequency of needlestick events. This informa¬ 
tion can help in determining how employees can 
maximally benefit from a product change to safer 
needle devices. Although not required by OSHA, 
the collection and evaluation of complete 
needlestick injury data are key to identifying 
injury patterns and then implementing an effective 
abatement plan. (See also, the sample "Safety 
Feature Evaluation Form," for help in determining 
the most appropriate device for your employees.) 

9 29 CFR, Part 1910.1030, (c)(l)(ii)(B) and (d)(2)(i). 

10 L.A. Chiarello, "Selection of Safer Needle Devices: A Conceptual 
Framework for Approaching Product Evaluation," Am ] Infection 
Control 23(6):386-395,1995. 

How Can I 
Get M ore 
or A ssistance 
on ThisTopic? 

For OSHA assistance, you can 
contact the bloodborne patho¬ 
gens coordinator in your 
nearest regional office listed 
elsewhere in this booklet. See 
also Other Resources listed in 
this brochure. OSHA also 

provides other services and assistance, including: 

• Consultation Program— This service is deliv¬ 
ered by state government agencies or universi¬ 
ties employing professional safety health and 
consultants. Primarily developed for smaller 
employers with more hazardous operations, 
comprehensive assistance includes an onsite 
appraisal of all work practices and environmen¬ 
tal hazards and all aspects of the employer's 
present job safety and health program. Largely 
funded by OSHA, the service is provided at 
no cost to the employer and is available on 
request to employers who want help in estab¬ 
lishing and maintaining a safe and healthful 

experience and expertise. For more information 
on VPP, contact your VPP coordinator in your 
nearest OSHA regional office. 

• Publications— OSHA has many published 
materials, including specific topics for small 
businesses, that are available or ordered online 
at Publications lists and single 
copies of various OSHA materials can be ob¬ 
tained by sending a self-addressed label to the 
OSHA Publications Office, PO. Box 3753, 
Washington, DC 20013-7535, or by calling 
(202) 693-1888. 

OSHA regulations are contained in Title 29 
of the Code of Federal Regidations, Parts 1904 
(Recordkeeping), 1910 (General Industry), 1911 
through 1925 (Maritime), 1926 (Construction), 
and 1928 (Agriculture). All OSHA regulations 
are available or can be ordered online at Printed copies of OSHA regula¬ 
tions are sold by the Government Printing Office 
and can be ordered online as indicated above. 

• Electronic Information— Internet: OSHA 
standards, interpretations, directives, interactive 
software, compliance assistance materials, and 
additional information are available or can be 
ordered on the World Wide Web at See in particular. Safer Needle 
Devices: Protecting Health Care Workers, under 
Index, Needlestick Injuries, and News Room, 
Publications, on the OSHA home page. 

CD-ROM: includes directives, standards, 
interpretations, and other materials on CD. 
Available from the U.S. Government Printing 
Office, Superintendent of Documents, PO. Box 
371954, Pittsburgh, PA 15250-7954 or at (202) 
512-1800. Specify OSHA Regidations, Documents, 
and Technical Information on CD-ROM, (ORDT), 
Order No. S/N729-013-00000-5; $43 per year 
and $15 per single copy. Issued quarterly. 

• Grants— OSHA gives training and education 
grants to various non-profit groups to develop 
programs to help small businesses establish 
safety and health programs. 

• Mentoring— OSHA's Voluntary Protection 
Programs (VPP) recognize worksites where 
employers and employees work together to 
achieve safety and health excellence. Small 
firms can be matched with and mentored by a 
VPP site that will share its safety and health 

• Small Business Liaison— OSHA's liaison is 
available to answer questions on small business 
issues at 202-693-2317. 

• State Plans— Twenty-five states and territories 
operate their own federally approved occupa¬ 
tional safety and health programs. The states 
conduct most OSHA enforcement through their 
own standards, which are at least as effective as 
Federal OSHA's, but may have different or 
additional requirements. Many states offer 
additional programs of assistance to small 
businesses. For more information on state 
plans, see the list of plans at the end of this 
brochure or visit Outreach on OSHA's Web site 

• Training and Education— OSHA's Training 
Institute in Des Plaines, IL, and OSHA's Training 
Education Centers provide basic and advanced 
courses in safety and health. OSHA's area offices 
offer information services, such as audiovisual 
aids, technical advice, and speakers for special 
engagements. For more information, contact the 
Institute at 1555 Times Drive, Des Plaines, IL 
60018, (847) 297-4810, or fax (874) 297-4874. A 
list of courses also can be found under Outreach 
on OSHA's Web site at 

Emergencies— For life-threatening situations only, 
call (800) 321-OSHA. Complaints will go immedi¬ 
ately to the nearest OSHA area or state office for 

Other Resources 

American Hospital Association— AHA report, 
December 1996, Implementing Safer Needle Devices 
(Item No. 196310). Call (800) AHA-2626 to order 

American Nurses Association— ANA position 
papers on safer needle devices. Call (202) 652- 7130. 

EPINet Program— Includes manuals and software, 
data collection tools, and tracking and reporting 
systems for surveillance of bloodborne exposures, 
tracking device specific injuries, and evaluating the 
efficacy of safer needle devices. Call EPINet Pro¬ 
gram (800) 528-9803. 

The Service Employees International Union's 
(SEIU) Guide to Preventing Needlestick Injuries— 
Includes a listing of safer needle devices, checklist 
for compliance with OSHA's bloodborne pathogen 
standard, safe device feature evaluation checklist, 
and guide for post-needlestick exposure followup. 
To order, send a check for $5.00 (pre-paid orders 
only) to the SEIU Mailroom, 1313 L St., NW Wash¬ 
ington, DC 20005. 

0 ther Websites 

CDC AIDS Clearinghouse 
EPINet - 
CDC Hepatitis Branch - 

OSHA Regional Offices - For more information, 
contact the bloodborne pathogens coordinator at 
the nearest OSHA Regional Office. 

Region I 

(CT/ MA, ME, NH, RI, VU) 

JKF Federal Building 
Room E-340 
Boston, MA 02203 
Telephone: (617) 565-9830 

Region II 

(NJ, NY/ PR/ VP) 

201 Varick Street 
Room 670 

New York, NY 10014 
Telephone: (212) 337-2378 

Region III 

(DC, DE, MD/ PA, VA/ WV) 
Gateway Building, Suite 2100 
3535 Market Street 
Philadelphia, PA 19104 
Telephone: (215) 596-1201 

Region IV 

(AL, FL, GA, KY/ MS, NC/ SC/ TN*) 
Atlanta Federal Center 
61 Forsyth Street, SW, Room 6T50 
Atlanta, GA 30303 
Telephone: (404) 562-2300 

Region V 

(IL, IN/ MI/ MN/ OH, WI) 

230 South Dearborn Street 
Room 3244 
Chicago, IL 60604 
Telephone: (312) 353-2220 

Region VI 

(AR, LA, NM/ OK, TX) 

525 Griffin Street 
Room 602 
Dallas, TX 75202 
Telephone: (214) 767-4731 

Region VII 
(IA/ KS, MO, NE) 

City Center Square 
1100 Main Street, Suite 800 
Kansas City, MO 64105 
Telephone: (816) 426-5861 

Region VIII 

(CO, MT, ND, SD, UT/ WY*) 

1999 Broadway, Suite 1690 
Denver, CO 80202-5716 
Telephone: (303) 844-1600 

Region IX 

(American Samoa, AZ/ CA/ Guam, HI/ NV/ Trust 
Territories of the Pacific) 

71 Stevenson Street 
Suite 420 

San Francisco, CA 94105 
Region X 

(AK/ ID, OR*, WA*) 

1111 Third Avenue 
Suite 715 

Seattle, WA 98101-3212 
Telephone: (206) 553-5930 

*These states and territories operate their own OSHA-approved job safety and health programs (Connecticut and New York 
plans cover public employees only). States with approved programs must have a standard that is identiical to, or at lease as 
effective as, the federal standard. 

U.S. Department of Labor 

Occupational Safety and Health Administration 
OSHA 3161 

The following is the most recent copy of the Sample “Safety Feature Evaluation Form,” devel¬ 
oped by the Training for Development of Innovative Control Technology Project (TDICT), Trauma 
Foundation, San Francisco General Hospital, 1001 Potrero Avenue, Building 1, Room 300, San 
Francisco, CA 94110. OSHA has permission to reprint this form in both traditional and electronic 
publishing formats. Since the form is copyrighted, however, extensive use of the form by others 
may require additional permission from the copyright holders. Other evaluation forms for different 
devices also are available from TDICT. 

Guidelines for the Use of 
Safety Feature Evaluation Sheets 


Determine which products are to be evaluated and provide at least four or more test 
samples for each individual evaluating the product. (Each evaluator should have enough 
samples to disassemble and examine the design thoroughly.) 

Set up a testing station for each type of device which allows testers to evaluate products in 
a simulated patient procedure. Provide training dummies (injection pads, oranges, etc.) as 

Provide visual instructions and demonstrate proper use of each device. 

Review the instructions and rating system with each evaluator. 

Encourage each evaluator to comment on the sheets and prioritize the questions at the end 
of the evaluation. This will provide a useful decision making tool and will help alert you to 
specific areas of concern which may not have been covered by the questionnaire. 


Re-enact all steps of intended or possible procedures performed with the device being 

Attempt to misuse the device and circumvent or disable the safety feature. 

Answer each question, including the short answer section at the end. If you do not under¬ 
stand a question, please write comments directly on the sheets. 

Note: Certain assumptions have been made in the development of these forms based on 
information about currently available products. We recognize the likelihood that the ideal 
product may not exist. 


Training for Development of Innovative Control Technology Project 

Safety Feature Evaluation Form 


Number of times used: 

Please circle the most appropriate answer for each question. Not applicable (N/A) may be used if 

the question does not apply to this particular product. 

During Use: agree.disagree 

1. The safety feature can be activated using a one-handed technique.1 2 3 4 5 N/A 

2. The safety feature does not obstruct vision of the tip of the sharp.1 2 3 4 5 N/A 

3. Use of this product requires you to use the safety feature.1 2 3 4 5 N/A 

4. This product does not require more time to use than a non-safety device...1 2 3 4 5 N/A 

5. The safety feature works well with a wide variety of hand sizes.1 2 3 4 5 N/A 

6. The device is easy to handle while wearing gloves.1 2 3 4 5 N/A 

7. This device does not interfere with uses that do not require a needle.1 2 3 4 5 N/A 

8. This device offers a good view of any aspirated fluid.1 2 3 4 5 N/A 

9. This device will work with all required syringe and needle sizes.1 2 3 4 5 N/A 

10. This device provides a better alternative to traditional recapping.1 2 3 4 5 N/A 

After Use: 

11. There is a clear and unmistakeable change (audible or visible) that occurs 

when the safety feature is activated.1 2 3 4 5 N/A 

12. The safety feature operates reliably.1 2 3 4 5 N/A 

13. The exposed sharp is permanently blunted or covered after use and prior to 

disposal.1 2 3 4 5 N/A. 

14. This device is no more difficult to process after use than non-safety 

devices.1 2 3 4 5 N/A 


15. The user does not need extensive training for correct operation.1 2 3 4 5 N/A 

16. The design of the device suggests proper use.1 2 3 4 5 N/A 

17. It is not easy to skip a crucial step in proper use of the device.1 2 3 4 5 N/A 

Of the above questions, which three are the most important to your safety when using this 

Are there other questions which you feel should be asked regarding the safety/ utility of this 


Training for Development of Innovative Control Technology Project