How to Prevent

Needlestick Injuries:

Answers to Some

Important Questions
More than 20 pathogens

have been reportedly transmitted from needlesticks.2

The most serious are the

transmission of Hepatitis C

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).

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 odp.od.nih.gov/consensus/statements/cdc/105/

105_stmt.html.1997.

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

Surveillance

Report 8(2): Atlanta, GA 1996. 6 Title 29 Code of Federal Regulations, Part 1910.1030.

Why Do I Need

to Worry About

Needlesticks?

When Might

My Employees

Be Injured

By a

Needlestick?

injections, draw blood, or handle trash or dirty

linens where needles have been inappropriately

discarded.

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.

Isn’t There Just

a Small Chance

of Such an

Injury?

What Can

Happen from

a Needlestick?

(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

Greater 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 hepatocellular carcinoma.4 Liver failure from Hepatitis C is

the leading reason for liver transplants in the U.S.

So, Do I Still

Need to Worry

About HIV

Exposures

for Employees?

Yes. The total number of

occupationally acquired HIV

infections in health care

workers continues to increase each year. Of the 52

such cases documented

during 1996, 45 were from

needlesticks or cuts.5

How Can I

Protect Employees

Against Potential

Exposures?

Make sure that employees

use universal precautions,

engineering and work

practice controls, and personal protective equipment

to reduce their exposure to

bloodborne pathogens, as required by OSHA’s

Bloodborne Pathogens Standard.6

If you’re an employer of

health care workers who are

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 Immunodeficiency Virus (HIV). Needlestick injuries

account for up to 80 percent of accidental exposures

to blood. Nurses in hospitals are the most frequently injured.

Needlestick injuries may

occur when employees

dispose of needles, collect

and dispose of materials

used during patient care

procedures, administer

Data from 63 hospitals show

that the overall rate of such

injuries is 27 per 100 occupied beds annually. Nurses

had the most frequent

Introduction

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.
Figure 2. Self-Resheathing Needle

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 forward over the needle where it locks in place

and provides a guard around the used needle.

You’re correct. Most

personal protective equipment can be easily penetrated by needles. Most

needlestick injuries, however, result from unsafe

Yes, that would be helpful.

For example, it is good to

know whether the feature is

active or passive or whether

the engineering control is

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,

1997.

8 Ippolito, et al, 1997.

Figure 1. Needleless IV Connector

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 plungertype system is shown here. These devices are passive and integral

to the system.

Can’t Needles

Penetrate Most

Personal Protective

Equipment?

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

A safer needle device has

built-in safety controls to

reduce needlestick injuries

before, during, or after use

and to make needlesticks

less likely.

What’s a Safer

Needle Device?

Not all needlestick injuries

are preventable, but the

number can be reduced by

using devices containing

needles with built-in safety

Will These

Devices Prevent

Needlestick

Injuries?

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

In general, properly

designed devices should

(1) provide a barrier between

the hands and the needle

after use; (2) allow or require

How Do These

Devices Work?

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.

Are There Specific

Safety Features

I Need to Know

About?

part of the device. Types of safety features include

the following:

• 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.
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 information 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.)

10 L.A. Chiarello, “Selection of Safer Needle Devices: A Conceptual

Framework for Approaching Product Evaluation,” Am J Infection

Control 23(6):386-395, 1995. 9 29 CFR, Part 1910.1030, (c)(1)(ii)(B) and (d)(2)(i).

No. OSHA does not require

employers to institute

specific devices, but it does

require that employers

evaluate the effectiveness of

existing controls and review

Does OSHA

Require the

Use of Specific

Devices?

the feasibility of instituting more advanced engineering controls. Further, OSHA’s Bloodborne

Pathogens Standard9 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 puncture and to record the injury on the OSHA 200 log

in some cases.

As an employer of health

care workers, you have the

flexibility to develop individual worksite-specific

needlestick prevention

programs to protect employees. Such a program would

mean that you have a

mechanism in place to select

and evaluate safer medical

What Steps Do

I Need to Take

to Have a

Comprehensive

Prevention

Program and to

Implement Safer

Needle Devices?

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

way.)

In addition, a comprehensive needlestick prevention 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

Source: Reprinted with permission of Training for Development of Innovative Control

Technology Project, June Fisher, M.D., June 1993.©
For OSHA assistance, you can

contact the bloodborne pathogens coordinator in your

nearest regional office listed

elsewhere in this booklet. See

also Other Resources listed in

this brochure. OSHA also

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 www.osha.gov. Publications lists and single

copies of various OSHA materials can be obtained by sending a self-addressed label to the

OSHA Publications Office, P.O. Box 3753,

Washington, DC 20013-7535, or by calling

(202) 693-1888.

OSHA regulations are contained in Title 29

of the Code of Federal Regulations, 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

www.osha.gov. Printed copies of OSHA regulations are sold by the Government Printing Office

and can be ordered online as indicated above.

• 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 occupational 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

at www.osha.gov.

• 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 www.osha.gov.

Emergencies—For life-threatening situations only,

call (800) 321-OSHA. Complaints will go immediately to the nearest OSHA area or state office for

help.

How Can I

Get More

Information

or Assistance

on This Topic?

provides other services and assistance, including:

• Consultation Program—This service is delivered by state government agencies or universities 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 environmental 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 establishing and maintaining a safe and healthful

workplace.

• 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

www.osha.gov. 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, P.O. Box

371954, Pittsburgh, PA 15250-7954 or at (202)

512-1800. Specify OSHA Regulations, 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
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 Washington, DC 20005.

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

U.S. Department of Labor

Occupational Safety and Health Administration

OSHA 3161

Other Resources

American Hospital Association—AHA report,

December 1996, Implementing Safer Needle Devices

(Item No. 196310). Call (800) AHA-2626 to order

copies.

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 Program (800) 528-9803.

Other Websites

CDC AIDS Clearinghouse -www.cdcnac.org

EPINet - www.med.virginia.edu~epinet

CDC Hepatitis Branch - www.cdc.gov/ncidod/

diseases/hepatitis/hepatitis.htm

OSHA Regional Offices - For more information,

contact the bloodborne pathogens coordinator at

the nearest OSHA Regional Office.

Region I

(CT,* MA, ME, NH, RI, VT*)

JKF Federal Building

Room E-340

Boston, MA 02203

Telephone: (617) 565-9830

Region II

(NJ, NY,* PR,* VI*)

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

*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.
The following is the most recent copy of the Sample “Safety Feature Evaluation Form,” developed 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

Coordinators:

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

necessary.

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.

Evaluators:

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

tested.

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 understand 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.

© June1993

Training for Development of Innovative Control Technology Project

SAMPLE
SAFETY FEATURE EVALUATION FORM

SAFETY SYRINGES

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

Training:

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

product?

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

product?

© June1993

Training for Development of Innovative Control Technology Project

SAMPLE