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Draft Needlestick Injury Report, version 6

Concept and Justification

We propose a dedicated injury reporting system for needlestick and sharps incidents. The objective is to remove
obstacles to rapid and complete reporting, to capture more significant information without additional effort or
cost, and to enter information on individual incidents in one file in one database for later analysis. The system
would be based on a menu-driven on-line initial reporting form to be completed by the injured party or supervisor.
The initial report would be linked to a follow-up investigation form accessible only to authorized parties,
specifically the infection control nurse investigating the incident. Once completed, all reports would be accessible
only to authorized parties.

Needlestick and sharps injuries represent a particularly complicated class of injury. Effective prevention requires
capturing information on numerous products, detailed information on circumstances, and the potential for
inoculation with infectious material. This information is impossible to obtain reliably and comprehensively using
only a free-response narrative report, such as the ### and ### forms, especially in the absence of prompts and
checklists, which are impractical. Indications are that the present system is not performing well.

Designed for prevention

Existing systems basically register the injury. The data contained in the report has no further use. Unless a pattern
is noticed, it will be overlooked and an opportunity for prevention may be lost. This form is designed to capture
information essential for injury prevention. In effect, this form is designed to fill in the essential elements of what
is called “Haddon’s matrix” in injury prevention, as below.

Instrument of injury Host (injured employee) Environment

(circumstances)
Conditions before the Product design Training Procedure being
event performed
Factors as the event Poor design causes failure Distracted or in a hurry Patient moves
happens
Factors after the event Guard or design prevents Employee recognizes risk Coworker recognizes
that change outcome deep injection (or doesn’t) and stops before problem and stabilizes
penetration (or doesn’t) patient (or doesn’t)
Haddon’s matrix allows lessons to be learned from individual case investigations. It also allows clusters of factors
to be identified rapidly by computer analysis so that problems can be solved.

Designed to capture data more completely and accurately

Because these injuries happen frequently, paper-driven systems are inefficient and costly to input into electronic
databases. Data entry also introduces errors. The experience of other hospitals and healthcare systems
demonstrates the value of collecting this information in a dedicated system but also suggests that on-line reporting
would be much more efficient, collect more accurate information, and would increase adherence to reporting
requirements. The system proposed for THE MEDICAL CENTRE would represent a significant advance over the
current systems and is consistent with best practices in the healthcare sector, specifically the reporting system
used by EPINet, a consortium of hospitals in the United States for sharing information on sharps injury frequency.
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Designed for on-line, menu-driven response

Sections 1 and either 2 or 3, as appropriate, are intended to be completed by the employee or by some other party
with responsibility or representing the employee (or a visitor). Each form is one page long or less (because the
drop-down menus save considerable space).

Section 4 is intended to capture data from an interview conducted to investigate the incident. It would be hidden
from the person doing the initial reporting but could be called up by the infection control nurse.

Development points

 All data on the incident would be recorded in one place and in an e-format for easy analysis.
 Having a single form prevents duplication and re-entering the same information.
 Sections 1 + either 2 or 3 yields data that can be used to calculate a risk score. This could be automated to
prioritize or flag incidents.
 All data should be confirmed by investigating infectious control nurse, so there would need to be some
sort of overwrite or edit capability that also preserves a record of the original.
 The on-line form would have the following features, coded as follows:
o Drop-down menus [Lists]
o Radio buttons (for exclusive alternatives), including one set placed on a graphic 
o Text entry windows ________
o Upload window { }
o Other instructions (( ))
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First webpage, to be filled out by injured employee or supervisor.

NEEDLESTICK AND SHARPS INJURY AND BODY FLUIDS EXPOSURE REPORT FORM

Identifying Information (Section 1)

Name of injured:___________________________________________________________________

Badge Number:____________________ Status: Regular:  Other:  [Menu, List D]

Male of Female: M F If female, check here if pregnant: 

Person Completing This Form: Self:  Other (identify): __________________________

Location of Incident: [Drop-down Menu List A]

Date and time of the incident: [Drop-down time and date: time : , day/month /year]

Job Classification: [Drop-down menu in reverse order of frequency, List B]

Is this a needlestick injury or sharps cut?

Yes:  Needlestick (Continue to Section 2) [Drop-down menus K, L1 and L2 should automatically appear
with Yes.]

Yes:  Other sharps (Continue to Section 2)

No:  (Proceed to section 3)

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Alternative second webpage, to be filled out by injured employee or supervisor.

Needlestick Injury and Sharps Cut (Section 2)

Type of Sharp: [Drop-down menu in reverse order of frequency, List C]

Product Identification: [Drop-down menu in reverse order of frequency, List K]

Body Part Stuck or Cut: [Drop-down List E]

How did the incident occur? [Drop-down menu, List F]

Did the device have a protective mechanism built in? No:  Yes: 

If yes, had the protective mechanism been removed or disabled? No:  Yes: 

Was a sharps container nearby and readily available for disposal of the sharp? No:  Yes: 

Before the injury occurred, had the device been inserted, used in surgery or a procedure, or otherwise come into
contact with body fluids of another person? No  Yes: [Drop-down List G]

Was the device previously in contact with any body fluid other than blood? No  Yes: [Drop-down List H]

Was there visible blood on the device or had it been previously inserted into a vein, artery, or body cavity of a
person? No:  Yes:  If yes, describe:__________________________________________

If the answer to the above is Yes, has the injured person reported to Staff Health for evaluation and triage for
prophylaxis?

No:  Why not?_____________________________________________________________

Not Yet:  Yes:  When is/was the appointment: [Drop-down time and date]

Did the needlestick or sharp draw blood on the injured person? No:  Yes: 

Did blood or body fluids enter the injured person’s body (under skin, by accidental injection):

No  Trace only  Enough to see  More 

Has the injured person already completed a hepatitis B vaccination series? No:  Yes: 

Had the injured person received training on THE MEDICAL CENTRE bloodborne pathogen protection [use official
name] in the last year? No:  Yes: 

Is the person on whom the sharp was previously used an inpatient or outpatient, with a THE MEDICAL CENTRE
medical record? No:  Yes:  If inpatient, are they still admitted and if so, where?________________

Check here if there is reason to believe that the person on whom the sharp was previously used is positive for one
of the following infections: HIV/AIDS, hepatitis B and C, tuberculosis. 

What are your (the injured person’s) recommendations on ways to prevent such incidents in the
future?______________________________________________________________________________
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Alternative second webpage, to be filled out by injured employee or supervisor.

Other Exposure to Body Fluids (Section 3)

Body part with contact: [Drop-down menu, List E]

Which body fluid was involved? [Drop-down menu, List H]

If skin, was the skin of the person exposed to the body fluids intact or was there a break in the skin? (A
break in the skin means a cut, abrasion, eczema, rash, or open wound.) No:  Yes: 

If eye, was the person exposed to the body fluids wearing eye protection at the time? No:  Yes: 

If mouth, was the mouth and lips of the person exposed to the body fluids normal or was there a break in
the surface? (A break in the surface means a sore, crack, cut, abrasion, or open wound.) No:  Yes: 

Was the body fluid wiped or washed off immediately? Yes:  No: 

Amount of blood or body fluid involved:

None  < 1 cc  1 to 5 cc  up to 50 cc  More 

Time that blood or body fluid was in contact with skin or mucous membrane:

< 1 minute  1 – 5 min  5 – 15 min  More  Explain why:______________

Has the injured reported to Staff Health for evaluation and triage for prophylaxis?

No:  Why not?_____________________________________________________________

Not Yet:  When is the appointment: [Drop-down time and date: time : , day/month /year]

Yes:  If so, when was the appointment: [Drop-down time and date: time : , day/month /year]

Did the needlestick or sharp cut draw blood? No:  Yes: 

Has the person exposed already completed a hepatitis B vaccination series? No:  Yes: 

Had the person exposed received training on THE MEDICAL CENTRE bloodborne pathogen protection [use official
name] in the last year? No:  Yes: 

Is the person on whom the sharp was previously used an inpatient or outpatient, with a THE MEDICAL CENTRE
medical record? No:  Yes:  If inpatient, are they still admitted and if so,
where?________________

Check here if there is reason to believe that the person on whom the sharp was previously used is positive for the
following infections: HIV/AIDS, hepatitis B and C, tuberculosis. 

Do not provide further information on this form about the person on whom the sharp was previously
used.
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What are your (exposed person’s) recommendations on ways to prevent such incidents in the
future?______________________________________________________________________________
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Alternative second webpage, to be filled out by person designated to investigate incident .

Interview and Investigation Results (Section 4 – restricted access to this page)

Depth of sharp penetration: No skin penetration  Shallow intradermal  Moderate  Deep 

Bleeding from the wound; None  Little  Some  Profuse 
Was the source patient identifiable? Yes  No  Unknown  Not applicable 
Was the source patient tested? No  Yes  (Specify below)
HIV  Hep B Ag  Hep B Ab  Hep C 
Has antiviral prophylaxis been started? No  Yes  Date: (Drop-down menu: / / )
How did the injury occur: [Drop-down menu, List I.]
Was the injured worker right or left handed? Right  Left  Ambidextrous (uses both) 
Was the injured employee the original user of the sharp? No  Unknown  Yes 
Was the injury intentional? No  Unknown  Yes 
(If Yes or Unknown, file a complete narrative report off-line.)
Was the injury self-inflicted? No  Unknown  Yes 
(If Yes or Unknown, file a complete narrative report off-line.)
What personal protection was the employee using at the time of the incident? [Drop-down menu, List J.]
On the body map provided, mark location of the injury.
Check here if there were multiple injuries and describe in narrative #1 
((Reproduce Cincinnati body map with radio buttons where numbers are in the original.))
Please complete the following fields or upload three narrative reports:
1. Narrative description of circumstances leading to the incident. [Mandatory]
Field for word processing:__________________________
{Upload window}
2. Narrative description of any malfunction, design flaw or manufacturer’s defect in the device being used.
If none, check here: Not applicable  _______________________________
[Field for word processing.]
{Upload window.}
3. Your recommendation on ways to prevent such incidents in the future. [Mandatory]
[Field for word processing.]
{Upload window.}___________________________
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Lists for Drop-Down Menus

List A. Location

A1. Specific THE MEDICAL CENTRE Facility

A2. Specific Location in Building

A3. Work Area:

 Intensive/critical care unit

 Phlebotomy / venipuncture center
 Emergency department
 Dialysis unit
 Housekeeping
 Operating room / recovery
 Procedure room or outpatient surgery
 Inpatient room
 Outpatient clinic
 Ambulance
 Central sterile supply
 Pathology services
 Blood bank
 Radiology
 Laundry
 Labor and delivery room
 Clinical laboratories
 Corridors or common areas (such as waiting room)
 Service, office, and support areas (business and management offices, storage, maintenance, mechanical,
loading dock, etc.)
 Other [Specify]:___________________________________________________

List B. Job Classification [Use THE MEDICAL CENTRE job titles]

 Nurse
 Phlebotomist / venipuncture / iv team
 Physician
 Dentist
 Dental hygienist
 Emergency medical technician
 Housekeeper
 Respiratory therapist
 Laboratory technician
 Ambulance technician / driver
 Laundry worker
 Student (any type)
 Security
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 Technologist
 Management / administration
 Visitor

List C. Type of Device

 Needles [Go to C1.]

 Surgical instruments [Go to C2.]
 Autopsy instruments [Go to C2]
 Laboratory and blood or other fluid collection devices [Go to C3.]
 Personal care and grooming [Go to C4.]
 [Go to C5.]

List C1. Needles and catheters

((List C1 should trigger Automatic drop-down menu for needle size, List L1 and L2, if these have not already
been filled out.))

 Suture needle
 Hypodermic needle attached to disposable syringe
 Hypodermic needle (butterfly) for intravenous infusion or venipuncture
 Hypodermic needle on blood collection device (Vacutainer®)
 Safety needle for medports
 Recapper & Syringe Holder
 Cannullas (Various products)
 Insulin syringe needle
 Spinal needle
 Iv catheter
 Blood gas syringe
 Dialysis catheter
 Central venous line
 Intra-arterial catheter
 Bone marrow biopsy aspiration catheter
 Biopsy needle
 Other [Specify]:_______________________________________

List C2. Surgical Instruments

 Scalpel
 Scissors
 Knife blade
 Trocars and guide wires
 Bone cutter or chipper
 Tenaculum
 Histology or microtome cutting blade
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 Retractors, hooks, other retention devices

 Pins and other implantable devices
 Cautery
 Glass syringe
 Suture material, staples or wire
 Forceps, hemostats, clamps, pick-ups, sounds
 Other [Specify]: _______________________________________

List C3. Laboratory equipment and blood or other fluid collection devices

 Lancet for glucose fingerstick

 Lancer “Quickheel” for infants
 Broken vacuum tube
 Capillary tube (Natelson)
 Specimen collection tube, other (including CSF)
 Glass slide
 Pipette
 Medication vial or ampule
 Broken glass
 Other [Specify]: _______________________________________

List C4. Personal grooming

 Razor, blade
 Electric razor
 Scissors
 Knife (other than eating utensil)
 Nail clippers or file
 Eating utensils
 Other [Specify]:________________________________________

List D. Status other than Regular Employee

 Consultant with THE MEDICAL CENTRE

 Contractor for Aramco
 MDF staff
 RAC staff
 Visitor

List E. Body Part

 Hand
 Eye
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 Nose
 Mouth
 Face and neck other than eye, nose, and mouth
 Arm
 Trunk (chest and abdomen)
 Legs and feet

List F. Circumstances of the Incident

 While performing venipuncture or procedure [Go to F1.]

 While in operative field during surgery [Go to F2.]
 While handling equipment or specimens [Go to F3.]
 When administering medication via medport
 During disposal, cleaning, housekeeping or maintenance [Go to F4.]
 Other:___________________________________________________________________

List F1. Venipuncture and procedures

 Venipuncture / phlebotomy
 Starting iv
 Inserting catheter into patient, vein or artery
 Manipulating needle or catheter in patient
 Withdrawing needle or catheter in patient
 Inserting catheter or trocar into body cavity

List F2. In operative field

 Incising (cutting) during surgery

 Incising (cutting)
 Passing or receiving surgical instrument
 Manipulating suture needle in holder
 Suturing
 Palpating or exploring
 During surgery otherwise, while handling instrument
 Dropped instrument
 Instrument or needle picked up wrong way
 Other [Specify]:_________________________________________________________

List F3. Handling equipment or specimens

 Processing blood specimens

 Processing specimens of other body fluids
 Broken glass container or syringe
 Passing or transferring equipment (other than in operating room)
 Transferring specimen from one container or holder to another
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 Sharp object dropped

List F4. Disposal, cleaning, housekeeping or maintenance

 Sharps left in trash

 Sharps left in bed, mattress or pillow
 Sharps found in linen / laundry
 Sharps left on tray, stand, table, by bedside or elsewhere in room
 Sharps on floor
 Sharps found in clothing
 Cleaning, decontaminating or sterilizing equipment
 Transferring equipment to be cleaned or sterilized
 Disassembling and repairing equipment
 Broken glass
 Sharps container overfilled
 Sharps container broken, opened or failed

List G. Previous Use of Device

 Vascular access (venipuncture / phlebotomy, central or arterial line, dialysis)

 Cutting (during surgery or procedure)
 Cutting
 Suturing
 Biopsy
 Driling (e.g. neurosurgery, orthopedics)
 Specimen container
 Receptacle for fluids (e.g. emesis basin, urine bag)
 Laboratory processing
 Repair and maintenance (e.g. use as tool)
 Other [Specify]:__________________________________________________

List H. Body Fluid

 Blood (please confirm by leaving blank if blood was not involved; choose “blood” in combination with
other bloody fluids if the fluid was visibly blood-stained)
 Cerebrospinal fluid
 Peritoneal dialysis fluid
 Aspirated fluid from body cavity: Synovial, pleural, peritoneal (ascites), pericardial, etc.)
 Amniotic fluid (delivery)
 Semen
 Vaginal secretions (gynecological procedures and obstetric procedures other than delivery)
 Urine
 Vomitus
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 Saliva
 Feces

List I. Mechanism of Injury

 Removing sharp from original packaging

 Starting iv or venipuncture
 During procedure, when sharp slipped or missed
 During procedure, when patient moved
 During multistep procedure, when something specific went wrong other than above
 Device left where it should not have been (table, bed, floor)
 Cleaning, disinfection, or sterilization, in preparation for reuse
 Splash or squirt from a container
 Splash or squirt from patient bleeding
 Withdrawing a need from rubber or plastic stopper, iv fitting
 Stuck or cut by sharp in trash
 Stuck by device sticking out of disposal container
 Stuck while putting sharp into disposal container
 Failure of sharps disposal container
 Stuck or cut by sharp inserted into mattress
 Recapping needle
 Other:_________________________________________________________

List J. Protection

 Single pair gloves, latex

 Double pair gloves, latex
 Single pair gloves, other than latex
 No gloves
 Goggles or face shield
 Eye glasses, spectacles
 Surgical mask
 Plastic or other impermeable apron
 Lab or clinic coat
 Surgical scrubs or gown
 N-95 respirator
 Other:_________________________________________________________

List K. Product/Model Manufacturer Identification

 Abbott
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 Advanced Medical
 Allegiance
 Allegiance Scientific
 Bard
 Baxter Edwards
 BD (Becton Dickinson)
 BD Insyte AutoGuard IV
 CLAVE IV Connector & HepLocks (Various products)
 Clinical Technology
 Cook
 Ethicon
 HMP
 Lifeguard
 Sherwood/Kendall
 StatLock Securement Devices (Various products)
 Other:________________________________________________
 Don’t know

List L. Needle Size

List L1. Gauge

 18G
 19G
 20G
 21G
 22G
 23G
 25G
 27G
 28G
 Don’t know

List L2. Length

 1/2 inch
 3/8 inch
 1/4 inch
 5/8 inch
 3/4 inch
 7/8 inch
 1 inch
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 1 1/2 inch
 2 inch
 2 1/2 inch
 3 inch
 3 1/2 inch
 Don’t know