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SHARPS SAFETY : ESSENTIAL CONCEPTS AND CONTROLS 1967

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Page 1: SHARPS SAFETY ESSENTIAL CONCEPTS AND CONTROLS

SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

1967

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1967SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability,negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions,or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independentverification of diagnoses, medication dosages, and individualized care and treatment should be made. The material containedherein is not intended to be a substitute for the exercise of professional medical or nursing judgment.

The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN,INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDINGBUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRDPARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The followingcredit line must appear on the front page of the photocopied document:

Reprinted with permission from AORN, Inc, 2170 South Parker Road, Suite 400, Denver, CO 80231-5711.

Copyright ©2013 “SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS”, All rights reserved

Video produced by Cine-Med, Inc.127 Main Street North, Woodbury, CT 06798 Tel (203) 263-0006 Fax (203) 263-4839

www.cine-med.com

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OVERVIEW/OBJECTIVES .............................................................................................................4 INTRODUCTION.............................................................................................................................5EPIDEMIOLOGY OF SHARPS INJURIES ....................................................................................5HIERARCHY OF CONTROLS FOR PREVENTING SHARPS INJURIES ..................................6

Hazard Elimination..................................................................................................................6Engineering Controls ...............................................................................................................7Work Practice Controls............................................................................................................8Administrative Controls ........................................................................................................10Personal Protective Equipment..............................................................................................11

RESPONDING TO A SHARPS INJURY.......................................................................................12SUMMARY.....................................................................................................................................13REFERENCES ................................................................................................................................14 POST-TEST.....................................................................................................................................17 POST-TEST ANSWERS.................................................................................................................20

SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

Sharps Safety: Essential Concepts and Controls

TABLE OF CONTENTS

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SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

OVERVIEWThe purpose of this study guide and accompanying video is to review essential concepts and practices to help perioperativenurses and other health care workers reduce injuries from sharps.

OBJECTIVESAfter viewing the video and completing the study guide, the participant will be able to:

1. Describe the most common causes of sharps injuries in perioperative and other health care settings.2. Discuss the hierarchy of controls critical in preventing sharps injuries.3. Describe the actions that should be taken when an occupational sharps injury occurs.

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SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

INTRODUCTIONThis learner guide reviews essential concepts and practices topromote sharps safety and reduce sharps injuries in theperioperative setting and other health care environments.AORN recommends these techniques to help nurses and othermedical and surgical personnel prevent bloodborne pathogenexposures during surgical and other invasive procedures andwhenever sharps are handled.

The guide reviews the prevalence and risk of sharps injuriesand defines and provides detailed examples and data tosupport the use of the hierarchy of controls, a model that ranksproven measures for preventing sharps injuries in theworkplace. Learners should be able to define the hierarchy,understand evidence for its efficacy, and provide detailedexamples of each component. Learners will also reviewimportant steps to take if a sharps injury occurs in theworkplace. These actions aim to reduce adverse outcomesfrom sharps injuries and prevent future injuries.

Proper use of the control measures described in this guide hasbeen shown to significantly decrease the incidence of sharpsinjuries. Perioperative nurses are responsible for implementingthe hierarchy of controls and taking additional steps to helpprotect themselves, their colleagues, and their patients fromthis workplace hazard.

EPIDEMIOLOGY OF SHARPS INJURIESSharps injuries are penetrating wounds caused by hollow-boreneedles, suture needles, scalpels, sharp surgical instruments,and other sharp medical objects. The Centers for DiseaseControl and Prevention estimates that every year, health careworkers in US hospital settings sustain at least 385,000 sharpsinjuries.1 This figure likely underestimates the true burden ofsharps injuries in the United States because the problem hasnot been well studied or monitored in non-hospital settingsand because as many as 50% of workplace sharps injuries gounreported.1

Sharps injuries place medical personnel at risk of infectionfrom viruses and other pathogens in blood and body fluids.Sharps injuries are mainly associated with the transmission ofHepatitis B (HBV) and C viruses (HCV) and humanimmunodeficiency virus (HIV), all of which can result inserious illness and death.1 However, more than 20 otherpathogens have been implicated in transmission after sharpsinjury, including Mycobacterium tuberculosis and herpes.1Although widespread vaccination in the United States hasdecreased the risk of HBV infection from sharps injuries,HBV remains an important concern for health care workers.Furthermore, the risk of HIV infection following a needlestickinjury from a contaminated needle has been estimated at 0.3%(95% confidence interval, 0.2%-0.5%), and occupational HIVinfection has been documented among surgical personnel.2,3,4

Sharps injuries persist as a major concern in surgical andperioperative settings. An analysis of percutaneous injury datafrom 87 US hospitals during 1993-2006 identified more than31,000 reported sharps injuries, 23% of which happened tosurgical personnel.5 The analysis found that after the USNeedlestick Safety and Prevention Act was passed in 2000,percutaneous injuries in nonsurgical settings decreased 32%,while sharps injuries in surgical settings increased by almost7%.5 The researchers concluded that the legislation was oftennot being adhered to in surgical environments.5Another studyperformed surveillance of blood exposure and exposure-prevention strategies in six OR suites, and identified 386reported percutaneous exposure events during a 15-monthperiod.6

Researchers have identified factors that increase the risk ofsharps injuries in health care environments. In a combinationretrospective/prospective analysis of needlestick injuries andnear misses from almost 1,700 hospital nurses, researchersfound that nurses who reported working in understaffed orpoorly organized units were approximately twice as likely tosustain a needlestick injury or to report a near miss comparedto their colleagues who did not report staffing or

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organizational problems.7 Another study of more than 3,000registered nurses in 60 acute hospitals found that reportedneedlesticks and other sharps injuries were associated withworking in perioperative units, working in environmentsdescribed as understaffed and under-resourced, feelingemotionally exhausted at work, possessing less workexperience, and not using safety engineered containers todispose of sharps.8

Perioperative nurses face special risks related to sharpsinjuries in the workplace. When surgeons and surgeryresidents sustain a sharps injury, they are typically the originalusers of the device.5 However, nurses and surgicaltechnologists are at risk of injury from devices used by otherhealth care workers – primarily surgeons, surgical residents,and surgical assistants.5 The majority of percutaneous sharpsinjuries occur to surgeons and surgical residents during use,while injuries to nurses and surgical technologists occurduring passing, disassembling, and disposal.

Sharps injuries also put patients at risk. If a health care workerhas a bloodborne infection and is injured by a sharp, patientscan be exposed and infected. Analyses of reported exposuresand infections indicate that health care worker-to-patienttransmission is most likely to occur in operating rooms.9 Since1991, there have been at least 132 confirmed cases worldwidein which health care workers transmitted HBV, HCV, or HIVto patients. Of these incidents, 131 occurred during invasivesurgeries.9

HIERARCHY OF CONTROLS FORPREVENTING SHARPS INJURIESThe hierarchy of controls is an important and widely usedmodel for reducing or eliminating hazardous exposures in theworkplace. The hierarchy of controls is ranked in a specificorder based on potential efficacy. At the top is the controlmeasure that is potentially most effective and protective inreducing or eliminating workplace hazards.

For prevention of sharps injuries, the hierarchy of controls in

descending order of importance is as follows:

• hazard elimination• engineering controls• work practice controls• administrative controls • personal protective equipment (PPE)1,10,11

Hazard Elimination Elimination of a hazard means removing sharp objects fromuse when possible.1,10,11 For example, electrosurgery might beused instead of a scalpel when making a surgical incision.

As an example of hazard elimination, many facilities haveimplemented needleless intravenous (IV) infusion systems inlieu of traditional IV systems that can be accessed withconventional or safety syringes. Several studies have reportedlower injury rates with use of these systems. For example, asix-month crossover clinical trial evaluated percutaneousinjuries among staff members at 16 medical and surgicalunits.12 The units implemented needleless intermittent accesssystems and conventional heparin-lock systems during phasesI and II of the study. Rates of percutaneous injuries weresignificantly lower (p=0.007) when the conventional IVsystems were eliminated and the needleless systems usedinstead. The needleless systems were not associated withincreases in nosocomial bacteria or injection-sitecomplications among patients.

Another study reported a 43% reduction in needlestick injuriesat an 1,100-bed tertiary care hospital in Canada after aheparinized lock IV system was eliminated and replaced witha needleless IV access system.13 Finally, a study at a medicalcenter in California reported a 72% decrease in needlestickinjuries during the first eight months after the facilityintroduced needleless IV systems that had blunt plasticcannulas and specially designed injection sites.14 Theresearchers found that staff reported satisfaction with the newsystem.

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Complete elimination of sharps is feasible for certain commonsurgeries.15 In a one-year study at an urban, university-basedsurgical practice, 25% of 358 procedures were identifiedpreoperatively as suitable for sharpless surgery.15 Of these,87% were completed without using sharps, including 59% ofopen laparotomies, 91% of laparoscopic procedures, and 98%of soft tissue procedures. Surgeons had the option to convertto using conventional suture needles and scalpels if necessaryduring all procedures.

Engineering ControlsWhen sharps must be used, the priority should be to reducethe risk of sharps injuries through the use of engineeringcontrols, which are safety-engineered devices designed toisolate or remove the sharps hazard.1,16 The federalNeedlestick Safety and Prevention Act of 2000 requiresemployers to provide safety-engineered devices in hospitalsand other health care settings.17 The American College ofSurgeons recommends the use of safety-engineered devicesduring surgery unless their use could negatively affect patientsafety or the safe performance of an operation.18 AORNspecifies that perioperative personnel must use sharps withsafety-engineered devices.10

Numerous studies indicate that the proper use of safety-engineered devices significantly decreases sharps injuries. Forexample, a meta-analysis of 17 studies found that rates ofpercutaneous injuries decreased between 22% and 100% aftersafety-engineered devices were introduced by health careorganizations.19

Suture needles cause most percutaneous injuries in the OR.5,20To help prevent these injuries, blunt-tip suture needles havebeen designed to be sharp enough to penetrate softer tissuesuch as muscle and fascia, but not sharp enough to easilypenetrate skin.21 Multiple studies support their effectivenessin reducing percutaneous injuries. A fixed-effect model meta-analysis of 10 randomized controlled trials of blunt versussharp needles found that surgeons who used sharp needles

sustained an average of one glove perforation in threeoperations, while the use of blunt-tip suture needles decreasedthe risk of glove perforations by almost 50% (relative risk,0.46, 95% confidence interval, 0.38-0.54).21 Furthermore,users deemed blunt-tip needles acceptable in five of sixstudies.21 AORN recommends the use of blunt-tip needleswhenever clinically appropriate, including for perineallaceration and episiotomy repair.10

Alternative wound closure methods can also be used to reducethe use of sharp suture needles in the OR. These includefascial closure devices, tissue staplers, tissue adhesives, andadhesive skin closure strips. Numerous randomized,controlled studies of humans have reported no significantdifference between use of suture and tissue adhesive in termsof infection rates, cost, and patient and user satisfaction. Forexample, a single-blind, randomized trial study found thatusing sterile adhesive closure strips on knee arthroscopy portalwounds was associated with significantly less swelling(p=0.02) and somewhat less pain compared to suture.22 Ameta-analysis of 14 randomized controlled trials of tissueadhesives for closure of surgical incisions found that tissueadhesive and suture performed similarly in terms of infectionrates, patient and user satisfaction and cost.23 However, suturewas faster to use and associated with lower rates of wounddehiscence. AORN recommends the use of alternativewound closure devices when clinically indicated.10

Scalpels are the second most common cause of sharps injuriesin the OR and comprise an estimated 17% of percutaneousintraoperative injuries.5 Perioperative nurses and otherassistants in the surgical team are at risk of scalpel injurieswhen scalpels are passed during surgery or the bladesremoved.5 Examples of safety scalpels include single-usescalpels, retracting scalpel blades, and blades with shields orsheaths to cover the blade when it is passed between teammembers.24 These safety engineered scalpels have thepotential to prevent 65% to 68% of percutaneous scalpel-related injuries.24 In addition, scalpel blade removal devices

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were found in a retrospective study and hypothetical model topotentially prevent 45% of injuries sustained during bladeremoval.25AORN recommends use of safety scalpels, whichare designed to reduce percutaneous scalpel injuries,whenever clinically feasible.10

The use of other engineering controls also has been shown tosignificantly reduce sharps injuries. Examples of other safety-engineered devices include safety-engineered syringes,needleless IV systems, and safety-winged butterfly needles.

In Pennsylvania, researchers tracked sharps injuries during athree-year period at a major medical center. Halfway throughthis period, the medical center introduced an IV catheter styletwith a safety-engineered retractable protection shield. Afterthis device was introduced, the incidence of percutaneousinjuries from IV catheters decreased significantly (p<0.01).During the surveillance period, the injuries from sutureneedles increased significantly (p<0.008), suggesting that thedecrease in IV catheter injuries was not to the result of otherfactors.26 AORN recommends that perioperative teammembers use syringes, needles, and IV catheters thatincorporate safety-engineered features.10

Work Practice ControlsWhen neither hazard elimination nor engineering controls areavailable or will not provide complete protection, workpractice controls should be used to prevent sharps injuries.1AORN specifies that under these circumstances,perioperative personnel must use work practice controlswhen handling scalpels, hypodermic needles, sutureneedles, bone fragments, K-wires, burrs, saw blades, drillbits, trocars, razors, bone cutters, towel clips, scissors,electrosurgical tips, skin hooks, retractors, and other sharpdevices.10

Work practice controls are intended to eliminate unsafepractices in the OR and perioperative environments. Examplesof unsafe practices include:

• passing sharps hand-to-hand between team members;• failing to use a safer sharps device when available and

not clinically contraindicated;

• incorrect sharps disposal;• using both hands to recap needles;• recapping needles when not necessary, and• manipulating suture needles with gloved hands.10

Instead of these hazardous practices, AORN recommendswork practice controls that include:10

• confining and containing sharps in specified areas ofthe sterile field or in a sharps containment device;

• using a neutral zone or hands-free technique forpassing sharp instruments, blades, and needles;

• using a no-touch technique for handling sharps;• using instruments to load or unload scalpel blades,

when feasible;• using alternative cutting methods, such as

electrosurgery or diathermy, when clinically indicated;• removing suture needles from suture before tying;• retracting tissue with instruments instead of hands;• maintaining situational awareness of sharps in the

sterile field;• telling team members where sharps are during

procedures and personnel changes;• cutting or using a protective cap to cover exposed pins

and K-wires after they have passed through a patient’sskin;

• using safe practices to withdraw body fluids and injectmedication; and

• handling all sharps devices with caution.The rest of this section reviews several work practice controlsin more detail.

Handling suture needlesSuture needles should not be handled with gloved hands.10Using gloved hands to load or reposition the needle in theneedle holder can result in injury. Instead, a suture packet

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should be used to position the needle in the holder withouttouching the needle.

Data indicate that the non-dominant hand is at greatest risk ofpercutaneous injury during suturing. A randomized clinical trialshowed that during episiotomy repair, 90% of glove perforationsthat occurred during suturing affected the non-dominant hand.27During suturing, a blunt instrument such as a forceps should beused to guide the needle through the tissue so that the fingersdo not touch either the needle or the incision site.

To reduce risk of percutaneous injury from a loaded sutureneedle, the perioperative team member who is suturingshould use a forceps to turn the suture needle 90° towardthe box lock of the needle holder before returning theloaded needle holder.10

Turning the loaded needle may reduce the risk of sharps injuryduring instrumentpassing.28

Collection and disposal of used sharpsUsed sharps are hazardous when not properly collected andcontained. Unconfined sharps in the sterile field can penetratedrapes, end up on the floor, or in the garbage where they mightharm personnel who are cleaning or disposing of trash. Usedsharps cause hazards for patients and can injure perioperativepersonnel and place other staff members at risk of inadvertentinjury during cleaning and similar activities. Research hasshown that sharps injuries can result from workers’ failure toproperly contain sharps as well as use of containers that areinadequately designed, inappropriately placed, or over-filled.29

AORN recommends that sharps be confined and containedin specified areas of the sterile field or within a sharpscontainment device. Sharps should not be removed fromthe OR until the final count reconciliation is complete andthe patient has been taken out of the room.10

Perioperative personnel play a central role in sharps collectionand disposal. It is the responsibility of the scrub person toconfine, contain, and count all sharps during invasiveprocedures.10 Within the sterile field, used sharps should bekept in a puncture-resistant container that is leak-proof. Whenneedle disposal containers on the sterile field are full, theyshould be replaced with new empty containers.

To protect medical personnel, contaminated reusable sharpssuch as trocars, osteotomes, saw blades, and skin hooks shouldbe kept separate from used non-sharp instruments. Thecontaminated sharps should be placed and in a puncture-resistant container with a biohazard label for transport to thedecontamination area. To prevent bloodborne pathogenexposures, the Occupational Safety and Health Administration(OSHA) prohibits decontamination processes that requireworkers to put their hands in basins of sharp instruments.

Outside the sterile field or the OR, sharps should bedisposed of in a closed, puncture-resistant container that iscolor-coded red or orange and labeled with a biohazardlabel.30 The container should be easily accessible, mountedon the wall or the floor, and replaced before it begins tooverflow.30

The neutral zoneMost sharps injuries occur during hand-to-hand passing ofsharps between team members, based on data from an analysisof injury data from 87 US hospitals during a 13-year period.5

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Use of a designated neutral (ie, hands-free) zone within thesterile field is an alternative to passing sharps hand-to-hand.This practice is recommended by AORN and by OSHA.10,31

To use the neutral zone:

• Team members should identify the neutral zone in thepreoperative briefing.

• The neutral zone may be a basin, instrument mat,magnetic pad, or designated area on the Mayo stand.Kidney basins should be avoided because it is too easyfor fingers to end up in the basin close to the sharp.

• During surgery, team members give verbalnotification (such as by saying “Sharp”) when a sharpis in the neutral zone.

• Only one sharp and one hand at a time should be inthe neutral zone.

• The sharp should be placed for easy removal by thesurgeon.

• After use, the sharp is returned to the neutral zone.10

During some procedures, the use of the neutral zone is notfeasible. For example, during microscopic surgeries thesurgeon cannot remove his or her eyes from the operativefield. At the same time, the low lighting, magnification, andnarrow field of vision during microscopic surgeries can increase

the risk of sharps injuries.32 Therefore, a modified neutral zoneshould be used as follows:

• After giving verbal notification, the scrub person placesthe sharp in the surgeon’s hand.

• The surgeon places the sharp in the neutral zone afteruse.10

One-handed recappingOne-handed recapping of needles is another important no-touchtechnique. For example, research indicates that one-handedscooping to recap needles is much safer than two-handedrecapping. In one study, sharps injuries among medical studentsdecreased from 17% to 3% after the students were trained touse the one-handed scooping technique to recap needles.33

AORN specifies that if a safe needle device is unavailableand a needle must be recapped, perioperative workersmust use a recapping device or one-handed scoopingtechnique.

To recap a needle using the one-handed scoop technique:

• Place the needle cap on a flat, stable surface. • Guide the needle into the cap while holding only the

syringe. • Do not touch the cap.• Lift the syringe so the cap is sitting on the needle hub

and secure the needle cap in place.30

Administrative ControlsThe next component of the hierarchy of controls isadministrative controls, in which perioperative and otherhealth care personnel develop, apply, and routinely evaluateand revise policies, procedures, plans, and education to reduceor eliminate bloodborne pathogen exposures that result fromsharps injuries.

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Exposure preventionAORN recommends that facilities develop and implementpolicies and procedures to reduce or eliminate the exposureof medical personnel to blood and other potentiallyinfectious substances. These should be readily available toclinical staff and should be periodically reviewed andrevised as needed.10

Exposure prevention policies and procedures promote safetywhen they are regularly reviewed and available in the practicesetting. Facilities must have written bloodborne pathogenexposure control plans that follow federal, state, and localrules and regulations and establish and define workrestrictions for health care workers who have transmissiblebloodborne infections such as HIV, HBV, and HCV. Theseplans also should specify processes for educating and trainingstaff, conducting competency evaluations, assessing theefficacy and utility of sharps safety devices, and performingannual reviews of issues that arise related to sharps safety.

Exposure prevention practices for which administratorsshould develop policies and procedures include:

• double-gloving (discussed in the next section);• use of the neutral zone;• use, selection, and evaluation of safety-engineered

devices, and• protocols for post-exposure prophylaxis and other

responses to a sharps injury.

Device evaluationNumerous engineered sharps devices are advertised on themarket and these devices have varying function, efficacy, andacceptability of use.34,35,36 For this reason, device evaluationis an important administrative control to help ensure that newsafety devices are effective, used properly, and acceptable tosurgical team members and other clinical staff.

When evaluating new sharps products and their safetyfeatures, health care professionals should consider worker andpatient safety, user acceptability, and efficiency. The OSHAand AORN recommend that new devices underconsideration be evaluated by front-line team memberstrained in correct use of the device.10,16

Evaluators should use a one-page survey tool to evaluate theproduct for a set time period, and the survey tool should beeasy to complete and score and should include a section forcomments. Final product selection should be based on surveyresults. After a new device is introduced, AORNrecommends that its proper usage, acceptance, andperformance be further assessed. Safety engineered devicesmust be evaluated every year.10,16

In addition, studies indicate that passive safety engineereddevices are more effective at preventing sharps injuries thanactive devices.37 Passive devices differ from active devices inthat they do not require the user to activate the safety featurefor the device to work properly.37

Team-based root cause analysisAnother administrative control is the implementation of ateam-based root cause analysis.10 This means using a qualityimprovement tool after any sharps injury to help identify theunderlying reasons for the accident and promote risk reductionstrategies. Root cause analyses are discussed in more detail inthe next section.

Personal Protective Equipment Perioperative personnel must use personal protectiveequipment (PPE) to help prevent sharps injuries. The useof appropriate PPE has been repeatedly shown to reduce therisk of sharps injuries.38 The OSHA requires workers to wearPPE when there is a risk of occupational exposure to blood,body fluids, or other potentially infectious materials.16 Usingproper PPE is the personal responsibility of perioperativenurses and other health care workers. This practice is partof professional responsibility that helps users, their colleagues,and patients.

Unfortunately, glove perforations remain commonplace in theOR.39,40 In two recent studies, glove perforations weredetected in 29% of urologic procedures and 50% to 91% oforal and maxillofacial surgeries.39,40 Of note, in the analysisof 1,436 gloves used during oral and maxillofacial surgery,scrub nurses were at highest risk for glove perforations(perforation rate, 63%), followed by surgeons and firstassistants (44%), and second assistants (16%).39

Glove perforations during surgery are especially risky becauseoral and maxillofacial procedures often involve substantialvolumes of blood or other potentially infectious body fluids,increasing the risk of exposure to bloodborne pathogens ifpercutaneous injury occurs. Glove perforations also place

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patients at increased risk for surgical site infections fromexposure to exogenous microbes from scrubbed skin.

Because of this, double gloving is an especially important useof PPE. Scrubbed team members should wear two pairs ofsurgical gloves whenever there is a risk of exposure toblood, body fluids, or other possibly infectious materialsduring a surgical or invasive procedure.10,41,42

Wearing two pairs of gloves helps protect the inner glove fromperforation and decreases the chance of the wearer’s skinbecoming exposed to bloodborne pathogens. This practice hasbeen shown to reduce exposure of skin after gloveperforations. A systematic Cochrane Database reviewevaluated 14 randomized controlled trials of double versussingle gloving.43 The analysis found a significantly higherodds of single glove perforations compared to perforations ofthe innermost of the double gloves (odds ratio [OR] 4.1, 95%confidence interval [CI] 3.3-5.1).43

In a prospective study, researchers randomly assigned medicalpersonnel performing 99 visceral surgeries to either singlegloving or double gloving.38 Team members who wore doublegloves had no perforations of their inner gloves, while 32%of single-glove wearers had glove perforations that they didnot notice until prolonged contact with infectious blood andbody fluids could have occurred.38 In the prospectiverandomized trial evaluating glove perforations during oral andmaxillofacial surgery, double gloving during orognathicsurgery resulted in a protection rate of 95%.39 In anotherrandomized prospective study of 63 first assistants and scrubnurses assigned to practice either single or double glovingduring abdominal surgery, comparable, perforations weredetected in 9% of single gloves and 11% of outer gloves, withno perforations of inner gloves.44

Although historically some health care providers have resisteddouble gloving for surgical and other invasive procedures, thepractice is gaining acceptance. Importantly, a US study of 53surgeons and surgeons-in-training found that double gloving

did not significantly change tactile sensitivity (p=0.66) ormanual dexterity (p=0.57).45

Double gloving is most effective when it includes the use ofperforation indicator systems, a practice shown to increasedetection of glove perforations before they result in prolongedexposures.38,43 In perforation indicator systems, a colored pairof gloves is worn inside a standard outer pair of gloves. If theouter glove is perforated, the colored underglove showsthrough, facilitating detection of the perforation.

In the Cochrane Database review, not using perforationindicator systems significantly decreased the odds of detectingperforations for both single gloves (OR 0.1, 95% CI 0.06-0.16) and the innermost pair of standard double gloves (OR0.08, 95% CI 0.04-0.17).43 In the study of 99 visceralprocedures, perforation indicator systems allowed immediatedetection of three of 16 outer glove perforations withoutexposure, and although 13 other perforations were notdetected, they did not result in prolonged exposure.38

Getting the right glove fit is important when double gloving.Because glove fit varies by manufacturer and glove type, itcan be useful to try different sizes of gloves. Some teammembers prefer the outer pair to be a half size larger than theirusual glove size, while others prefer the opposite strategy orthat both pairs of gloves be the same size.

RESPONDING TO A SHARPS INJURYIf a needlestick or another sharps injury occurs, the workershould immediately wash the wound with soap and water andseek medical treatment.46 The injury should be reported to asupervisor as soon as possible, and the risk of infection shouldbe evaluated based on the infection status of the source patientand the presence of blood and other body fluids at the time ofinjury. If a worker is splashed with blood or anotherpotentially infectious substance the affected skin, nose, ormouth should be flushed with water and eyes, if splashed,should be irrigated with saline, sterile irrigant, or clean water.

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Employers are required by law to anonymously report toOSHA all needlestick injuries and cuts from sharp objects thatare contaminated with another person’s blood or otherpotentially infectious material including human body fluids,tissues, organs, and other materials such as laboratory culturesor tissues potentially infected with HBV or HIV.16 Splasheswith blood or other potentially infectious material must alsobe logged and reported if the splash results in a bloodborneinfection.

The OSHA 300 Log excludes the affected worker’s name toprotect his or her privacy, but must include the location, jobtitle, description of incident, and type and brand of sharpinvolved. Employers are also responsible for source testing,risk analysis, and providing post-exposure prophylaxis, ifneeded.

A root-cause analysis should be performed to determine theunderlying reason for the injury. The focus of the root causeanalysis should be on processes, not personal fault. Within 48hours of the injury, facts should be gathered from teammembers who were present and should be reviewed anddiscussed by a response team.

SUMMARYPreventing sharps injuries during fast-paced, high-pressuresurgeries can be challenging. But doing so is crucial to protectpatients and health care workers. Reducing sharps injuriesrequires a rigorous commitment to safety and communicationboth in and outside the OR. AORN encourages perioperativenurses and other team members to take the lead in developing,refining, and implementing policies and procedures that applythe hierarchy of controls to help eliminate and reducepercutaneous injuries from suture needles, scalpels, and othersharp medical objects. Furthermore, personnel should respondpromptly and appropriately if sharps injuries occur and notifycolleagues if they observe unsafe handling of sharps or otherproblems that could lead to bloodborne pathogen exposures.

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REFERENCES1. Workbook for Designing, Implementing, and Evaluating A Sharps Injury Prevention Program. 2008. Centers for

Disease Control and Prevention. http://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf. Accessed May8, 2013.

2. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workersafter percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N EnglJ Med. 1997;337(21):1485-1490.

3. US Public Health Service: Updated US Public Health Service guidelines for the management of occupationalexposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR.2001;50(RR11):1-52.

4. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med. 2003;348(9):826-833.5. Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. Increase in sharps injuries in surgical settings versus

nonsurgical settings after passage of national needlestick legislation. AORN J. 2011;93(3):322-30.6. Sharps Injuries in the Operating Room: Massachusetts Sharps Injury Surveillance System Data, 2004. April 2008.

Massachusetts Department of Public Health. http://www.mass.gov/eohhs/docs/dph/occupational-health/sharps-injuries-operate-room-04.pdf. Accessed May 22, 2013.

7. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries tonurses. Am J Public Health. 2002;92(7):1115-1119.

8. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. Factors associated with needlestick and sharp injuries amonghospital nurses: a cross-sectional questionnaire survey. Int J Nurs Stud. 2012;50(8):1025-1032.

9. Perry JL, Pearson RD, Jagger J. Infected healthcare workers and patient safety: a double standard. Am J InfectControl. 2006;34(5):313-319.

10. Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. 2014: 351-385.

11. Alexander’s Care of the Patient in Surgery. 14th Ed. Rothrock JC, ed. Mosby, 2011.12. Mendelson MH, Short LJ, Schechter CB, et al. Study of a needleless intermittent intravenous-access system for

peripheral infusions: analysis of staff, patient, and institutional outcomes. Infect Control Hosp Epidemiol.1998;19(6):401-406.

13. Yassi A, McGill ML, Khokhar JB. Efficacy and cost-effectiveness of a needleless intravenous access system. Am JInfect Control. 1995;23(2):57-64.

14. Skolnick R, LaRocca J, Barba D, Paicius L. Evaluation and implementation of a needleless intravenous system:making needlesticks a needless problem. Am J Infect Control. 1993;21(1):39-41.

15. Makary MA, Pronovost PJ, Weiss ES, et al. Sharpless surgery: a prospective study of the feasibility of performingoperations using non-sharp techniques in an urban, university-based surgical practice. World J Surg. 2006Jul;30(7):1224-1229.

16. 29 CFR Part 1910. Occupation Exposure To Bloodborne Pathogens; Needlestick and Other Sharps Injuries; FinalRule. Occupational Safety and Health Administration (OSHA).http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=16265Accessed May 22, 2013

17. United States Congress. Needlestick safety and prevention act. 2000. http://www.gpo.gov/fdsys/pkg/PLAW-106publ430/html/PLAW-106publ430.htm/ Accessed February 24, 2014.

18. American College of Surgeons. Statement on sharps safety. Bull Am Coll Surg. 2007; 92(10).http://www.facs.org/fellows_info/statements/st-58.html. Accessed January 23, 2014.

19. Tuma S, Sepkowitz KA. Efficacy of safety-engineered device implementation in the prevention of percutaneousinjuries: a review of published studies. Clin Infect Dis. 2006;42(8):1159-1170.

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20. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORNJ. 1998;67(5):979-981, 983-984, 986-987.

21. Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneousexposure incidents in surgical staff. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD009170.

22. Sikand M, Murtaza A, Desai VV. Healing of arthroscopic portals: a randomised trial comparing three methods ofportal closure. Acta Orthop Belg. 2006;72(5):583-586.

23. Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure ofsurgical incisions. Cochrane Database Syst Rev. 2010 May 12;(5):CD004287.

24. Perry J, Parker G, Jagger J. Scalpel blades: reducing injury risk. Adv Exposure Prev. 2003;6(4):37-40.25. Fuentes H, Collier J, Sinnott M, Whitby M. Scalpel safety: modeling the effectiveness of different safety devices’

ability to reduce scalpel blade injuries. Intern J Risk Safety Med. 2008;20(1-2):83-89.26. Azar-Cavanagh M, Burdt P, Green-McKenzie J. Effect of the introduction of an engineered sharps injury

prevention device on the percutaneous injury rate in healthcare workers. Infect Control Hosp Epidemiol.2007;28(2):165-170.

27. El-Refaie TA, Sayed KK, El-Shourbagy MA, Arafat EA. Role of blunt suture needle in episiotomy repair atuncomplicated vaginal deliveries in reducing glove perforation rate: a randomized controlled trial. J ObstetGynaecol Res. 2012;38(5):787-792.

28. Kunishige J, Wanitphakdeedecha R, Nguyen TH, Chen TM. Surgical pearl: a simple means of disarming the“locked and loaded” needle. Int J Dermatol. 2008;47(8):848-849.

29. Selecting, evaluating, and using sharps disposal containers. NIOSH publication no. 97-111. Cincinnati, OH:NIOSH; 1998. http://www,stacks.cdc.gov/view/cdc_6386_DS1.pdf. Accessed January 23, 2014.

30. Sharps Safety in the OR: Let’s Walk the Talk. 2011. AORN, Inc.http://www.aorn.org/Clinical_Practice/ToolKits/Sharps_SafetyTool_Kit/Supporting_Documents/SSTK_Sharps_Safety_in_the_OR_Presentation.aspx. Accessed May 9, 2013.

31. The Use Of Safety-Engineered Devices And Work Practice Controls In Operating Rooms; Hospital ResponsibilityTo Protect Independent Practitioners Under BBP Standard. United States Department of Labor OccupationalSafety and Health Administration.http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=25620 ed.2007. Accessed January 23, 2014.

32. Ghauri AJ, Amissah-Arthur KN, Rashid A, Mushtaq B, Nessim M, Elsherbiny S. Sharps injuries in ophthalmicpractice. Eye. 2011;25(4): 443-448.

33. Froom P, Kristal-Boneh E, Melamed S, Shalom A, Ribak J. Prevention of needle-stick injury by the scooping-resheathing method. Am J Ind Med. 1998;34(1):15-19.

34. Black L. Chinks in the armor: Percutaneous injuries from hollow bore safety-engineered sharps devices. Am JInfect Control. 2013;41(5):427-432.

35. Ford JL, Phillips P. How to evaluate sharp safety-engineered devices. Nurs Times. 2008;104(36):42-45.36. Jagger J, Perry J, Gomaa A, Phillips EK. The impact of U.S. policies to protect healthcare workers from

bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health. 2008;1(2):62-71.37. Tosini W, Ciotti C, Goyer F, et al. Needlestick injury rates according to different types of safety-engineered

devices: results of a French multicenter study. Infect Control Hosp Epidemiol. 2010;31(4):402-407.38. Caillot JL, Paparel P, Arnal E, Schreiber V, Voiglio EJ. Anticipated detection of imminent surgeon-patient barrier

breaches. A prospective randomized controlled trial using an indicator underglove system. World J Surg.2006;30(1):134-138.

39. Kuroyanagi N, Nagao T, Sakuma H, Miyachi H, Ochiai S, Kimura Y, Fukano H, Shimozato K Risk of surgicalglove perforation in oral and maxillofacial surgery. Int J Oral Maxillofac Surg. 2012;41(8):1014-1019.

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40. Feng T, Yohannan J, Gupta A, Hyndman ME, Allaf M. Microperforations of surgical gloves in urology: minimallyinvasive versus open surgeries. Can J Urol. 2011;18(2):5615-5618.

41. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver,CO: AORN, Inc; 2014: 351-374.

42. Cicconi L, Claypool M, Stevens W. Prevention of transmissible infections in the perioperative setting. AORN J.2010;92(5):519-527.

43. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2006 Jul19;(3):CD003087.

44. Guo YP, Wong PM, Li Y, Or PP. Is double-gloving really protective? A comparison between the glove perforationrate among perioperative nurses with single and double gloves during surgery. Am J Surg. 2012;204(2):210-215.

45. Fry DE, Harris WE, Kohnke EN, Twomey CL. Influence of double-gloving on manual dexterity and tactilesensation of surgeons. J Am Coll Surg. 2010;210(3):325-330.

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SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

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1. A hierarchy of controls should be used to preventsharps and injuries in health care settings. TheCORRECT order of implementation, ranked frompotentially most effective to least effective, isa. hazard elimination, engineering controls, work

practice controls, administrative controls, PPEb. hazard elimination, work practice controls,

engineering controls, PPE, administrative controlsc. engineering controls, hazard elimination,

administrative controls, work practice controls,PPE

d. hazard elimination, engineering controls, PPE,work practice controls, administrative controls

e. PPE, work practice controls, administrativecontrols, engineering controls, hazard elimination

2. Cases of bloodborne pathogen transmission fromsharps injuries are primarily the result of________________, although more than 20 otherpathogens have been implicateda. HBV, HCV, and HIVb. HBA, HBV, and HIVc. HAV, HBV, and HCVd. HBA, HBV, and HAV

3. Sharps injuries in the OR are especially hazardousbecause surgical procedures often involve substantialamounts of blood and other possibly infectious bodyfluids. The most common cause of sharps injuries inthe OR is _______________, followed by_______________a. scalpels, bone cuttersb. scalpels, syringesc. sharp suture needles, scalpelsd. hypodermic syringes, sharp suture needles

4. All of the following are examples of hazardelimination for sharps safety EXCEPTa. using electrosurgery instead of a scalpel when

making a surgical incisionb. requiring at-risk health care workers to

participate in annual trainings on sharps safetyc. ensuring that the facility only uses needleless

IV systemsd. eliminating the use of injectable needles when

feasible and clinically appropriate

5. Examples of appropriate administrative controls toprevent sharps injuries include all of the followingEXCEPTa. developing and updating sharps policies and

proceduresb. incorporating sharps safety prevention into a

new or existing committee structurec. allowing only doctors to handle sharpsd. educating and training employees on the proper

handling and disposal of sharps and safety-engineered devices

6. All are UNSAFE practices in the OR EXCEPTwhich of the following?a. passing sharps hand-to-hand between team

members during orthopedic surgeryb. waiting until after surgery to say something if

you observe unsafe sharps handlingc. carefully recapping contaminated needles using

a scooping techniqued. disposing of sharps in an unlabeled bag

7. Which of the following is NOT an appropriate workpractice control to prevent sharps injuries in the OR?a. use of a neutral or safe zone when passing

sharps between team membersb. grasping and manipulating needles and scalpel

blades with instruments or suture packs insteadof fingers

c. wearing a colored pair of gloves outside astandard pair during surgery

d. during microscopic surgeries, placing the sharpin the surgeon’s hand and having the surgeonplace the sharp in the designated neutral zoneto return it to the scrub person

e. grasping a needle with a blunt instrument whensuturing

POST-TEST

SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

Multiple choice assessment. Select the response that best answers each question.

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8. Which of the following is NOT an appropriateresponse to a sharps injury in the workplace?a. immediately wash the area with soap and water

and seek medical treatment b. report the injury to your supervisor as soon as

possiblec. report the injury to your supervisor only if the

wound becomes infectedd. discuss with your supervisor the risk of

infection based on the infection status of thepatient and the presence of blood and otherbody fluids at time of injury

9. Choose the FALSE statement about introducingsafety engineered sharps devices in health caresettings?a. sharps products under consideration should

primarily be evaluated by administrators whocan compare them to benchmarking standards

b. sharps products under consideration by afacility should be evaluated by front-line userstrained in correct use of the device

c. final product selections should be based onresults of a one-page tester survey tool that iseasy to complete and score and includes roomfor comments

d. safety engineered devices must be evaluatedevery year

10. Bloodborne pathogen exposure control plans mustconform to all of the following EXCEPTa. be written and must follow federal, state and

local rules and regulationsb. establish and define work restrictions for health

care workers who have transmissiblebloodborne infections

c. specify processes for education, training,competency evaluation, evaluation of theefficacy and utility of sharps safety devices, andannual review of sharps safety issues

d. be posted in every room in which sharps arehandled

11. Double gloving is an example of using PPE toreduce the risk of sharps injuries. Based on availableevidence about its effectiveness, double glovingshould be practiceda. when the surgeon gives consent to do sob. during all surgical proceduresc. when there is a written policy requiring the use

of double gloves during surgeryd. when the surgical patient is known to have a

bloodborne pathogen infection

12. Engineering controls help prevent sharps injuries.Which statement about safety engineered devices isFALSE?a. safety engineered devices include blunt-tip

needles, single-use scalpels, retractable scalpels,and needles with sliding sheaths or needleguards

b. studies have not yet shown that safetyengineered devices significantly reduce needle-stick injuries, but they should be used anywayas a precaution

c. safety engineered devices should be used duringsurgery unless their use could negatively affectpatient safety

d. blunt-tip needles are safety engineered devicesdesigned to penetrate muscle and fascia, but notskin

13. Which statement about neutral zones is FALSE?a. a kidney basin is appropriate for a neutral zoneb. the neutral zone should be designated during

preoperative briefingc. when moving a sharp to the neutral zone, give

verbal notice such as saying “sharp”d. only one sharp and one hand at a time should

be in the neutral zonee. the sharp should be positioned for easy retrieval

by the surgeon

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14. If a needle must be-recapped, the proper techniqueto use isa. hold the cap with your fingers sideways and

slide the needle into the cap with your otherhand

b. with the cap on a stable, flat surface, guide theneedle into the cap while holding only thesyringe attached to the needle, then tip up thesyringe so the cap sits on the needle hub andsecure the cap in place

c. hold the syringe vertically while sliding the capover the needle

d. use both hands to center and push the cap ontothe needle.

15. Which of the following is NOT an appropriate wayto prevent sharps injuries in the OR?a. communicating the location of sharps on the

sterile field during personnel changesb. removing suture needle from suture before

tyingc. using double-gloved hands to retract tissued. cutting the exposed ends of sharp pins or K-

wires, or covering them with a protective capafter they have passed through a patient’s skin

16. Needleless systems should be used whena. withdrawing fluids from multi-use vialsb. withdrawing body fluids after establishing

initial accessc. administering fluids or medicationsd. withdrawing IV fluidse. a, b, and cf. b, c, and dg. a and dh. a, b, c, and d

17. Select the FALSE statement about alternativewound closure.a. Tissue adhesive is comparable to suture in terms

of infection rates, cost, and patient and usersatisfaction.

b. Tissue adhesive enables faster wound closurethan suture.

c. Tissue adhesive can be associated with higherrates of wound dehiscence than suture.

d. Other examples of alternative wound closuredevices include tissue staplers and adhesive skinclosure strips.

18. If a sharps injury occurs during a surgery, employersmusta. report the name of the injured worker and

details of the exposure to OSHAb. conduct source testing and risk assessmentc. take responsibility for post-exposure

prophylaxisd. b and ce. a and b

19. Select the FALSE statement. To reduce the risk ofinjuries to staff and patients during invasiveprocedures, the scrub person shoulda. stack used non-sharp instruments on top of

contaminated reusable sharps for transport tothe decontamination area

b. use needle-counting devices to contain andisolate sharps on the sterile back table

c. place used needles in a disposable, puncture-resistant needle counter that is appropriatelylabeled or color-coded and leak-proof on thesides and bottom

d. make sure sharps are not removed from the ORuntil the final count reconciliation is done andthe patient has been removed from the room

20. Sharps disposal containers in the perioperative areaoutside the sterile field should be a. kept on a table behind other equipmentb. replaced as soon as they begin to overflowc. open containers as long as they are labeled with

a biohazard symbold. leak-proof, puncture-resistant, and closeable

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SHARPS SAFETY: ESSENTIAL CONCEPTS AND CONTROLS

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POST-TEST ANSWERSSHARPS SAFETY: ESSENTIAL CONCEPTS and CONTROLS

1.a2. a3.c4.b5.c6.c7.c8. c9.a10.d11.b12.b13.a14.b15.c16.d17.b18.d19.a20.d