AORN Guidance Statement: Sharps Injury
Prevention in the Perioperative Setting
Introduction have the highest risk of injury and sustain more
than half (ie, 59%) of percutaneous injuries in the
The purpose of this guidance document is to assist perioperative setting.6 Scrub personnel experienced
perioperative registered nurses in the development the second highest frequency of percutaneous
of sharps injury prevention programs using identified injury, followed by anesthesia care providers and
best practices to reduce percutaneous injuries. It circulating nurses.6
also suggests strategies to overcome obstacles to Injuries from hollow bore needles constitute the
compliance with established sharps safety protocols. majority of injuries and pose the highest risk of
The perioperative setting is a high-risk environ- exposure to bloodborne pathogens.10 Although the
ment, and perioperative RNs are routinely faced risk of injury from hollow bore needles is prevalent
with high risk for exposure to bloodborne pathogens in the perioperative setting, the epidemiology of
from percutaneous injuries. Although the scope of sharps injuries in the OR is different from that of
the problem is not completely known, the National other locations in health care. Suture needles have
Institute for Occupational Safety and Health been identified as the most frequent mechanism of
(NIOSH) estimates that 600,000 to 800,000 percuta- percutaneous injury in the OR; they are involved in
neous injuries occur annually among heath care as many as 77% of such injuries.4,6 Scalpels are the
workers.1 Percutaneous injuries primarily are associ- second most frequent mechanism of injury, fol-
ated with occupational transmission of the hepatitis lowed by retractors, skin or bone hooks, and sharp
B virus (HBV), hepatitis C virus (HCV), and HIV, but electrosurgical tips.11,12
they may be implicated in the transmission of more Percutaneous injuries often are self-inflicted.
than 20 other pathogens. 2 Understanding the Studies indicate that 6% to 16% of these injuries
etiology of percutaneous injuries in the perioperative occur during hand-to-hand passing of sharp instru-
setting is paramount to developing a safe prevention ments, suture needles, and other sharp devices.
program. The most common body part injured is the non-
dominant hand. Injuries from suture needles occur
Background most often
♦ when loading the needle holder or reposi-
Percutaneous injuries occur throughout all health tioning the needle;
care facilities, and many occur in the perioperative ♦ during hand-to-hand passing of sharp devices
setting.3,4 Exposure to bloodborne pathogens occurs between scrub personnel and the surgeon;
during all phases of the perioperative process. ♦ during suturing, particularly muscle and fas-
Research indicates that injuries from sharp devices cia (eg, wound closure) when the needle is
or instruments occur in 7% to 15% of all surgical being manipulated and guided with fingers;
procedures. Procedures identified as posing the ♦ when retracting or stretching tissue with
highest risk of injury are thoracic, trauma, burn, hands;
emergency orthopedic, major vascular, intra- ♦ when the surgeon sews toward his or her
abdominal, and gynecologic surgeries.5 Risk of a own or an assistant’s hand;
sharps injury increases during more invasive, ♦ when tying suture with the needle attached;
longer procedures that result in higher blood loss.6 ♦ after the suture has just been used and remains
Fatigue resulting from working extended hours in unattended on the operative field—even if
combination with the fast pace of the perioperative suture is unattended on the field for only a short
environment also may contribute to increased risk time, the needle holder can fall off the field
of percutaneous injuries.7-9 onto a health care worker’s foot, or scrubbed
Nurses comprise the largest segment of health personnel may reach for it in an attempt to pre-
care workers and are reported to sustain the high- vent it from sliding off the field; and
est number of percutaneous injuries overall. 2 ♦ when placing the used needle in an over-
Observational studies have demonstrated that peri- filled sharps container.3
operative personnel experience the highest percu- Injuries from scalpels most often occur
taneous injury rates, but 70% to 96% of exposures ♦ when loading or removing a disposable
were underreported.5 Surgeons and first assistants scalpel blade on a reusable knife handle;
2005 Standards, Recommended Practices, and Guidelines 199
Sharps Injury Prevention
♦ during hand-to-hand passing of the scalpel; in the development and implementation of strate-
♦ during dissection when the tissue is being gies to reduce the risk of sharps injuries to health
retracted or spread with hands; care team members.
♦ when cutting toward the surgeon’s or an Perioperative nursing management should work
assistant’s fingers; with the facility risk manager or safety officer to
♦ immediately before or after use when the identify the types of sharp devices and how they
scalpel is left on the operative field unat- are used in the perioperative setting. Both perioper-
tended—even if this is for only a short time, ative nursing management and the risk manager or
the scalpel can fall off the field onto a health safety officer should have a thorough understand-
care worker’s foot, or scrubbed personnel ing of OSHA’s standards.3
may reach for it in an attempt to prevent it By law, an effective sharps injury and blood-
from sliding off the field; and borne pathogen exposure control program must be
♦ when the scalpel is placed in an over-filled or written, communicated to all workers in the peri-
poorly located sharps container.3 operative setting, and uniformly supported and
Glove barrier failure is a common occurrence in enforced by perioperative leadership.2,13 A multidis-
the perioperative setting. Glove failures can be ciplinary team is key to the success of this process.
caused by punctures, tears by sharp devices, or This team, using steps consistent with the continu-
spontaneous failures. These failures expose the ous quality improvement process, must conduct a
wearer to bloodborne pathogens. Studies have baseline assessment and set priorities for develop-
demonstrated that glove perforations often occur ing an action plan.2,6
after an average of 40 minutes of use during surgical
procedures. When two pairs of gloves are worn (ie, Perioperative-Specific
double gloving), in most instances, only the outer
glove is perforated when punctured by a sharp Risk Reduction Strategies
device. In addition, research demonstrates that when
two pairs of gloves are worn and a puncture occurs, ■ Adopt and incorporate safe habits into daily
the volume of blood on a solid sharp device (eg, work activities when preparing and using sharp
suture needle) is reduced by as much as 95%. There devices.
is evidence that double gloving can reduce the risk ■ Focus attention on the intent of the action when
of exposure to blood and body fluids, if the outer working with sharp items, and minimize rushing
glove is punctured, by as much as 87%.6 and distractions while applying safety tech-
niques during critical moments.
The Occupational Safety and Health Administra-
■ During preparation for operative or other inva-
tion (OSHA) requires health care organizations to
protect their workers and have a written exposure
inspect the surgical field for adequate lighting
control plan. Protection occurs by using universal
and space to perform the procedure;
precautions, engineering controls, work practice
organize the work area so that the sharps are
controls, organizational controls, and communica-
always pointed away from staff members;
tion. The standard also requires employers to main-
establish a separate area to place a reusable
tain a log of injuries from contaminated sharps.13
sharp for safe handling during the procedure;
Guidance Statement use standardized sterile field set-ups; and
include identification of the neutral zone in
The perioperative environment poses unique chal- the preoperative briefing.14
lenges for reducing the risk of injuries from sharp ■ During the operative or other invasive procedure:
devices. Surgery involves precise, regimented wear two pairs of gloves (ie, double gloving);
actions that require planning, communication, and monitor gloves for punctures;
team work. These same elements can be employed encourage the use of blunt suture needles;
to mitigate the inherent hazards associated with use neutral or hands-free technique for pass-
sharp devices encountered in the perioperative set- ing sharp items whenever possible or practi-
ting. Perioperative RNs should actively participate cal, instead of passing hand-to-hand;
200 2005 Standards, Recommended Practices, and Guidelines
Sharps Injury Prevention
give verbal notification when passing a sharp do not place hands or fingers into a container
device; to dispose of a device; and
keep visual contact with the procedure site keep hands behind the sharp tip when dis-
and the sharp device; posing.3,14,18
take steps to control the location of the sharp Health care organizations and their employees
device; are responsible for actively participating in strategies
be aware of other staff members in the area to reduce percutaneous injuries. The employing
when handling a sharp device; facility should provide an environment that reduces
keep track of and account for all sharp items the risk of percutaneous injuries from contaminated
throughout the procedure; sharp devices. A well-developed safety program and
contain used sharps on the sterile field in a support from management sends a clear message to
designated, disposable, puncture-resistant employees about the organization’s commitment to
needle container, and replace it as necessary; preventing injuries and keeping employees safe.
check to be sure the disposable, puncture- Fewer percutaneous injuries are reported in organi-
resistant needle container is securely closed zations that have a strong culture of safety. Individ-
before handing it off the field; ual health care workers have a responsibility to be
load suture needles using the suture packet to educated about the prevalence and mode of trans-
assist in mounting the suture needle in the mission of bloodborne pathogens and to use meas-
needle holder, and use the appropriate instru- ures to protect themselves.19
ment to adjust and unload the needle;
remove the needle from the suture before
tying, or use “control-release” sutures that
allow the needle to be removed with a RNs’ Responsibilities
straight pull on the needle holder;
activate the safety feature of a safety engi- ■ Observe local, state, and federal regulations (eg,
neered device immediately after use accord- OSHA regulations).
ing to manufacturers’ instructions; ■ Comply with methods to protect yourself from
keep hands away from the surgical site when disease transmission (eg, get the hepatitis B
sharp items are in use (eg, suturing, cutting); vaccination).
use one-handed or blunt instrument-assisted ■ Use devices with safety features that are pro-
suturing techniques to avoid finger contact vided by your employer.
with the suture needle or tissue being ■ Prevent hollow bore percutaneous injuries dur-
sutured; ing injections or bodily fluid retrieval by using
provide a barrier between the hands and the needleless systems or sharps with engineered
needle after use; and sharp injury protection devices whenever
use gloves and an instrument to pick up sharp possible;
items (eg, suture needles, hypodermic nee- retractable, protective sheath or self-resheathing,
dles, scalpel blades) that have fallen on the self-blunting, or hinged re-cap needles to
floor.2,3,6,13-17 administer local anesthetics and other injectable
■ During postprocedure clean up: medications;
inspect the surgical setup used during the blunt cannulas to withdraw medications and
procedure for sharps; fluids from vials; and
transport reusable sharps in a closed, secure the one-handed recapping technique, only if
container to the designated clean-up area; no other alternatives exist.
inspect the sharps container for overfilling ■ Practice using safety devices to establish famil-
before discarding disposable sharps in it; iarity and experience with them before using
make sure the sharps container is large them in practice.
enough to accommodate the entire device; ■ Actively participate in the safety conversion
avoid bringing hands close to the opening of process and help others adapt to the change.
a sharps container; ■ Use personal protective equipment.
2005 Standards, Recommended Practices, and Guidelines 201
Sharps Injury Prevention
■ Use sharps receptacles that are ■ Evaluate the effectiveness of established risk
identifiable (ie, orange, orange-red), closable, reduction strategies and products, provide feed-
and labeled with the biohazard symbol; back, and modify them as necessary to reduce
appropriately sized with a full line that is the risk of percutaneous injuries.7
readily visible; ■ Establish staffing patterns that minimize
puncture resistant and leak proof; extended work hours and allow for adequate
located close to the point of use; recuperation to decrease the risk of fatigue-
maintained upright when in use; and related injuries.20
routinely replaced and not allowed to overfill.
■ Participate in education about bloodborne Overcoming Obstacles to Compliance
pathogens, and follow recommended infection
prevention practices. Psychosocial and organizational factors may
■ Support and guide perioperative team members impede change. An employee’s risk-taking person-
to follow these risk reduction strategies. ality profile, perception that the organization is not
■ Encourage perioperative staff members to proac- committed to worker safety, and a perceived belief
tively report hazards that pose a threat of percu- that there is a conflict between providing optimal
taneous injury. patient care and protecting oneself from exposure
■ Know the location in your department of the contribute to an employee’s resistance to changing
exposure control plan. to safer practices.2 For example, although percuta-
■ Follow exposure control policy if injured (ie, neous injuries continue to occur in the periopera-
wash site with soap and water, provide immedi- tive setting, 71% of respondents in a national sur-
ate care to the exposure site).9,13 vey indicated that they have not evaluated blunt-tip
suture needles for use in the OR, and only 2% of
Employer Responsibilities respondents have fully implemented blunt-tip
suture needles. Only 14% of respondents had
■ Comply with local, state, and federal regulations implemented safety scalpels into their ORs.4
regarding percutaneous injury prevention. Changes in attitudes about risk of exposure must
■ Create a safety-oriented culture. occur before practice can change to comply with
■ Encourage timely reporting of all percutaneous sharps safety protocols. It is difficult to change
injuries by all perioperative team members. ingrained habits. People are most likely to change
■ Analyze needle-stick and other sharps-related behavior when they perceive a significant personal
injuries in the perioperative setting to identify risk. Education about the risk of contracting a
hazards and injury trends. bloodborne disease from a percutaneous injury
■ Establish a communication mechanism to seek with a contaminated sharp device should be pre-
input from perioperative team members regard- sented in the early stages of a health care worker’s
ing risks specific to the perioperative setting. career in order to develop safe practice habits.5
■ Provide training for all perioperative personnel Surgery involves precise, regimented actions
that includes risk reduction strategies designed requiring planning, communication, and team
specifically to address the risks encountered in work. These same elements can be employed to
the perioperative setting. overcome obstacles to compliance with measures
■ Evaluate and select safety devices that are meant to mitigate the inherent hazards of sharp
acceptable to all members of the perioperative devices encountered in the perioperative setting.
team who use them. The safety device should Suggested strategies to overcome obstacles to com-
provide features that work effectively, are reli- pliance include the following.
able, do not compromise patient or worker ■ Use frequent and multiple training methods that
safety, and are ergonomically designed to the include audiovisual aids, articles, hands-on clin-
acceptable specifications of the users. ical practice, and visual reminders (eg, lami-
■ Provide and have readily available the appropri- nated posters).
ate sharps safety devices, and provide adequate ■ Develop a multidisciplinary sharps injury pre-
training on their use. vention education plan.
202 2005 Standards, Recommended Practices, and Guidelines
Sharps Injury Prevention
■ Incorporate sharps injury prevention instruction products to reduce sharps injury in the OR. Staff
into initial nursing education to promote well- members who work with the product are key com-
established, safe habits. ponents of the team. A strong interdisciplinary com-
■ Include sharps injury prevention strategies dur- mitment to best practices and worker safety is the
ing orientation of new employees. optimal foundation necessary for change to occur.
■ Form a multidisciplinary sharps safety commit- ■ Review the literature for research about the
tee that includes, but is not limited to, perioper- mechanism, frequency, time, and place of
ative RNs, surgeons, anesthesia care providers, injuries, as well as the role and body part of the
surgical technologists, and first assistants. This person sustaining the percutaneous injury to
team could be asked to determine priority areas on which to focus.
help with the selection and evaluation of ■ Identify the products to be evaluated. Focus on
acceptable safety devices (eg, scalpels that their intended use in the facility and identify any
employ a one-handed technique or are totally special technique or design factors that will
disposable) and influence safety, efficiency, and user acceptabil-
work with physicians to explore alternative ity. Seek data from all sources on the safety and
techniques, such as adhesive skin closures; overall performance of the devices.
alternatives for securing catheters; use of blunt ■ Ensure that participants in the evaluation repre-
suture needles, rounded scalpels, or stapling sent all of the end users. To ensure a successful
devices, when procedurally appropriate; and evaluation, users must have adequate training.
use of alternative methods for cutting tissue Use clear, objective, consistent criteria to evalu-
(eg, harmonic scalpel, rounded scissors, laser ate safety devices.
devices, electrosurgery active electrodes). ■ Continue to monitor a safety device after it has
■ Network with other facilities to learn about their been implemented to assess performance and to
success stories. identify if there is a need for additional training.2,10
■ Collaborate with personnel who use the device,
and facilitate change instead of dictating change. Summary
■ Inform perioperative team members about cur-
rent research on disease transmission from per- Occupational exposure to bloodborne pathogens
cutaneous injuries and relate it to the individ- via percutaneous injuries is one of the most serious
ual’s experience. dangers perioperative team members face on a daily
■ Work with resisters to gain buy-in to the sharps basis. The risk of sustaining a percutaneous injury
safety program. can be decreased through employee education,
■ Remove as many conventional sharp items as clear communication, device engineering, and
possible from stock. focused work practice controls. Risk reduction
■ Create a culture of safety in which every team strategies should include specific practices aimed at
member is empowered to call attention to defi- reducing the unique risks of percutaneous injuries
ciencies in sharps management.2,9,12,13 encountered in the perioperative environment.
AORN recognizes the various settings in which peri-
operative RNs practice, and the suggested risk
Selecting and Evaluating reduction strategies in this guidance statement are
New Products intended to be adaptable to any setting where surgi-
cal or other invasive procedures are performed.
As risk reduction strategies are identified, a multidis-
ciplinary team should evaluate and select the best NOTES
products to meet the facility’s needs. An ongoing 1. “AORN position statement on workplace safety,” in
review process should be developed to assess, eval- Standards, Recommended Practices, and Guidelines (Den-
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2. “Workbook for designing, implementing, and evaluat-
ation and selection should include the following. ing a sharps injury prevention program,” Centers for Disease
■ Assemble a multidisciplinary team to develop, Control and Prevention, http://www.cdc.gov/sharpssafety
implement, and evaluate a process for selecting (accessed 5 Jan 2005).
2005 Standards, Recommended Practices, and Guidelines 203
Sharps Injury Prevention
3. ECRI, “Sharps injuries in the operating room—A 13. “Regulations (Standards–29 CFR) Bloodborne
new focus for OSHA,” Operating Room Risk Management pathogens 1910.1030,” Occupational Safety and Health
(December 2004) 1-5. Administration, http://www.osha.gov/pls/oshaweb/
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204 2005 Standards, Recommended Practices, and Guidelines