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CONTINUING EDUCATION Implementing AORN Recommended Practices for Sharps Safety DONNA A. FORD, MSN, RN-BC, CNOR, CRCST 2.2 www.aorn.org/CE Continuing Education Contact Hours indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evalua- tion at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feed- back on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #14503 Session: #0001 Fee: Members $17.60, Nonmembers $35.20 The CE contact hours for this article expire January 31, 2017. Pricing is subject to change. Purpose/Goal To provide the learner with knowledge specific to preventing sharps injuries and bloodborne pathogen exposure. Objectives 1. Discuss legislation related to preventing bloodborne pathogen transmission. 2. Discuss causes of percutaneous injury in perioperative settings. 3. Identify hazards associated with percutaneous injury. 4. Identify controls (ie, engineering, work practice, admin- istrative) that can be used to help prevent sharps injuries. 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertifi- cation, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. Conflict of Interest Disclosures Ms Ford has no declared affiliation that could be perceived as posing potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as CE for RNs. This rec- ognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2013.11.013 106 j AORN Journal January 2014 Vol 99 No 1 Ó AORN, Inc, 2014

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CONTINUING EDUCATION

Implementing AORNRecommended Practicesfor Sharps Safety

DONNA A. FORD, MSN, RN-BC, CNOR, CRCST 2.2

www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by

reading this article, reviewing the purpose/goal and objectives,

and completing the online Examination and Learner Evalua-

tion at http://www.aorn.org/CE. A score of 70% correct on the

examination is required for credit. Participants receive feed-

back on incorrect answers. Each applicant who successfully

completes this program can immediately print a certificate of

completion.

Event: #14503

Session: #0001

Fee: Members $17.60, Nonmembers $35.20

The CE contact hours for this article expire January 31, 2017.

Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge specific to preventing

sharps injuries and bloodborne pathogen exposure.

Objectives

1. Discuss legislation related to preventing bloodborne

pathogen transmission.

2. Discuss causes of percutaneous injury in perioperative

settings.

3. Identify hazards associated with percutaneous injury.

4. Identify controls (ie, engineering, work practice, admin-

istrative) that can be used to help prevent sharps injuries.

5. Describe actions perioperative RNs can take to assist in

preventing sharps injuries and bloodborne pathogen

transmission.

106 j AORN Journal � January 2014 Vol 99 No 1

AccreditationAORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s

Commission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-

cation, as well as other CE requirements.

AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check with

your state board of nursing for acceptance of this activity for

relicensure.

Conflict of Interest DisclosuresMs Ford has no declared affiliation that could be perceived as

posing potential conflict of interest in the publication of this

article.

The behavioral objectives for this program were created by

Liz Cowperthwaite, senior managing editor, and Rebecca

Holm, MSN, RN, CNOR, clinical editor, with consultation

from Susan Bakewell, MS, RN-BC, director, Perioperative

Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell

have no declared affiliations that could be perceived as posing

potential conflicts of interest in the publication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as CE for RNs. This rec-

ognition does not imply that AORN or the American Nurses

Credentialing Center approves or endorses products mentioned

in the activity.

http://dx.doi.org/10.1016/j.aorn.2013.11.013

� AORN, Inc, 2014

RECOMMENDED PRACTICES

E

Implementing AORNRecommended Practices

for Sharps Safety

http://dx.doi.org/10.1016/j.a

� AORN, Inc, 2014

DONNA A. FORD, MSN, RN-BC, CNOR, CRCST 2.2

www.aorn.org/CE

ABSTRACT

Prevention of percutaneous sharps injuries in perioperative settings remains a

challenge. Occupational transmission of bloodborne pathogens, not only from pa-

tients to health care providers but also from health care providers to patients, is a

significant concern. Legislation and position statements geared toward ensuring the

safety of patients and health care workers have not resulted in significantly reduced

sharps injuries in perioperative settings. Awareness and understanding of the types

of percutaneous injuries that occur in perioperative settings is fundamental to

developing an effective sharps injury prevention program. The AORN “Recom-

mended practices for sharps safety” clearly delineates evidence-based recommen-

dations for sharps injury prevention. Perioperative RNs can lead efforts to change

practice for the safety of patients and perioperative team members by promoting the

elimination of sharps hazards; the use of engineering, work practice, and adminis-

trative controls; and the proper use of personal protective equipment, including

double gloving. AORN J 99 (January 2014) 107-117. � AORN, Inc, 2014. http://

dx.doi.org/10.1016/j.aorn.2013.11.013

Key words: sharps injuries, sharps injury prevention, engineering controls, work

practice controls, administrative controls, blunt-tip needles, neutral zone, double

gloving.

ven with legislation in place that requires

safeguards and practice controls, perioper-

ative team members continue to experience

occupational percutaneous injuries at unacceptable

levels.1 Eight years after the passage of the Needle-

stick Safety and Prevention Act,2 Jagger et al1,3 re-

ported that although sharps injuries had decreased

31.6% in nonsurgical settings, they had increased

orn.2013.11.013

6.5% in surgical settings. Percutaneous injuries can

result in occupational transmission of hepatitis B,

hepatitis C, and HIV.4

The purpose of the new “Recommended prac-

tices for sharps safety”5 is to prevent percutaneous

injuries by helping perioperative nurses identify

potential sharps hazards, implement best practices,

and develop policies and procedures related to safe

January 2014 Vol 99 No 1 � AORN Journal j 107

January 2014 Vol 99 No 1 FORD

practices and postexposure protocols. AORN rec-

ommended practices represent what is considered

to be optimal and achievable perioperative nursing

practice and are based on the highest level of evi-

dence available. This article highlights the most

significant recommendations of the “Recommended

practices for sharps safety,” including those that can

have the largest effect on sharps injury reduction.

More in-depth information and a review of evi-

dence for each recommendation can be found in the

complete recommended practices (RP) document.5

WHAT’S NEW

The new “Recommended practices for sharps

safety” supersedes the “AORN guidance state-

ment: Sharps injury prevention in the perioperative

setting,”6 developed in 2005. The intent of the

guidance statement was to assist perioperative

RNs in developing sharps injury prevention pro-

grams and overcoming obstacles to compliance

with the suggested and mandated practices. Federal

regulations and strong research evidence provided

support for a stronger position on sharps safety,

so the RP document was developed to replace

the guidance statement.

Although many of the responsibilities and risk-

reduction strategies from the guidance statement

have been carried over into the RP document, the

new document provides the format of recommen-

dations followed by evidence-based rationales,

evidence-rated intervention statements, and sup-

porting activity statements. The evidence sup-

porting the recommendations is derived from

regulatory controls, randomized controlled trials,

and Cochrane systematic reviews.

RATIONALE

Approximately 500,000 health care workers each

year experience percutaneous injuries.3,7 Percuta-

neous injuries are associated with occupational

transmission of hepatitis B virus, hepatitis C virus,

and HIV, which can result in lifelong health con-

cerns.4 Percutaneous injuries also present a risk to

patients; a health care provider who is infected with

108 j AORN Journal

a bloodborne pathogen and who then receives a

percutaneous injury can inadvertently infect a pa-

tient through contact with the contaminated sharp

or contact with the health care provider’s blood

through an unnoticed glove perforation. Between

1991 and 2005, 132 cases of health care provider-

to-patient transmission of hepatitis B, hepatitis C,

or HIV were documented.8

Anyone who has experienced an occupational

exposure to bloodborne pathogens knows the emo-

tional burden of fear, worry, and concern that fol-

lows, which may be far greater than the actual

physical injury. The real or potential economic

burdens also can cause additional stress. Costs to

the health care worker are any expenses incurred

because of missed work days. Potential economic

burdens include the inability to continue working

because of an illness that results from the occu-

pational exposure. Costs to the employer include

the postexposure management, the laboratory tests

and follow-up testing, and any necessary prophy-

laxis, as well as loss of productivity of the health

care worker. The annual cost of percutaneous sharps

injuries has been estimated at $65 million.9 The

cost for a health care facility to manage an occu-

pational exposure can range from $71 to $4,838

per exposure.10

Two significant pieces of legislation, the Blood-

borne Pathogens Standard 29 CFR x1910.1030 in

199211 and the Needlestick Safety and Prevention

Act in 2000,2 are aimed at reducing occupational

transmission of bloodborne pathogens. The purpose

of the Bloodborne Pathogens Standard is to limit

health care worker exposure to bloodborne patho-

gens and other potentially infectious materials by

requiring implementation of engineering controls

(eg, use of safety-engineered devices) and work

practice controls (eg, use of a neutral zone for

passing sharps).12 The additional legislation in

2000 directed the Occupational Safety and Health

Administration (OSHA) to make multiple revisions

to the existing Bloodborne Pathogens Standard.

The Needlestick Safety and Prevention Act includes

requirements that annual review of exposure control

RP IMPLEMENTATION GUIDE: SHARPS SAFETY www.aornjournal.org

plans also should “reflect changes in technology

that eliminate or reduce exposure to bloodborne

pathogens.”2 Because medical technology is con-

stantly changing and improving, more devices are

becoming available that can help reduce sharps

injuries.13

In addition to AORN, a number of professional

associations have issued statements supporting

sharps injury prevention practices. These asso-

ciations include the American Academy of

Orthopaedic Surgeons,14 the American Col-

lege of Surgeons,15 the Association of Surgical

Technologists,16 and the Council on Surgical and

Perioperative Safety.17 In 2012, the International

Healthcare Worker Safety Center at the University

of Virginia, Charlottesville, released a consensus

statement endorsed by 20 organizations citing

improved sharps safety in surgical settings as the

highest priority in reducing percutaneous sharps

injuries.18 Three governmental agencies, the US

Food and Drug Administration, the National

Institute for Occupational Safety and Health,

and OSHA, issued a joint safety communication

in May 2012 encouraging the use of blunt-tip

suture needles.19

Accrediting bodies (eg, The Joint Commission,

the Accreditation Association for Ambulatory

Health Care) and regulatory organizations (eg,

OSHA, the Centers for Medicare & Medicaid

Services) may survey for sharps safety during

visits to health care facilities. Key points in a

survey could include review of the exposure

control plan, which must be in compliance with

the federal legislation and should meet the criteria

established in the Needlestick Safety and Pre-

vention Act.13 Surveyors also may look to en-

sure that sharps containers are located close to

the point of use and glove boxes and personal

protective equipment (PPE) are placed in conve-

nient locations. Other potential points in a survey

include a review of policies, sharps injury logs,

and documentation of safety training. Surveyors

may observe use of PPE and question personnel

about safety procedures.20

DISCUSSION

Implementing a sharps injury prevention program

can be a challenging process in any setting. The

“Recommended practices for sharps safety” pro-

vides information that can assist with developing

a bloodborne pathogens exposure control plan11;

eliminating the hazards; and implementing engi-

neering controls, work practice controls, and ad-

ministrative controls.5 Engineering controls are

practices that remove the hazard from the work-

place, such as the use of safety-engineered de-

vices.11 Work practice controls minimize the risk

of exposure to blood and other potentially infec-

tious materials by changing the method of per-

forming a task.11,21,22 Administrative controls

include developing policies and procedures and

providing education and training on prevention

of bloodborne pathogen exposure.

Recommendation I

Health care facilities must have a bloodborne

pathogens exposure control plan, as required by

OSHA.11 The exposure control plan is a component

of administrative controls, which are important to

the success of a sharps safety program. The plan

must include an exposure determination for em-

ployees who have the potential to be exposed to

blood and body fluids; a plan to reduce sharps in-

juries, including prioritized risk-reduction strate-

gies; and a process to monitor sharps injury data.

The plan must be reviewed and updated at least

annually and any time new practices are imple-

mented. Ensuring compliance with the exposure

control plan and related policies is important to

show commitment to prevention of sharps injuries.

Administrators and managers, in collaboration

with occupational health and infection prevention

practitioners, can develop the exposure control

plan. Frontline personnel, including perioperative

RNs and surgeons, should be involved in identi-

fying control methods to prevent sharps injuries by

using the hierarchy of controls to prioritize pre-

vention interventions (Figure 1).23 At the top of

the hierarchy (ie, the most effective strategy) is

AORN Journal j 109

Figure 1. The hierarchy of controls. Illustrationreprinted with permission from AORN, Inc, Denver,CO. All rights reserved.

January 2014 Vol 99 No 1 FORD

eliminating the hazard by completely removing it

from use. Eliminating the hazard (eg, a sharp item

or instrument) involves identifying alternative ways

to perform the necessary task without using sharps,

such as by using a tissue adhesive and adhesive

strips or a skin stapler to close a skin incision.

A systematic review of 14 randomized controlled

trials that evaluated surgical wound healing when

tissue adhesives were used for skin closure showed

there was no significant difference in infection

rates, patient and user satisfaction, or cost between

use of sutures and use of adhesives.24 Therefore,

when clinically indicated, it could be appropriate

to use adhesives in place of suture to help prevent

needlestick injuries.

The highest priority should be eliminating the

device that has the potential to cause the most

injuries.5 If eliminating use of the device is not

feasible, controls at lower levels of the hierarchy

should be considered, such as using engineering

controls, work practice controls, administrative

controls, and PPE.23

Recommendation II

When elimination of sharps is not feasible, peri-

operative team members must use sharps with

safety-engineered devices that “isolate or remove

the risk of bloodborne pathogen exposure.”11 Sharps

110 j AORN Journal

with engineered sharps injury protection have a

built-in safety feature and include blunt-tip suture

needles,4,15,17,25-28 safety scalpels,11 and safety-

engineered syringes and needles.11,23 Alternative

wound closure devices and needleless systems

are effective in preventing percutaneous injuries11

and include fascial closure devices, tissue sta-

plers, tissue adhesives, and adhesive skin closure

strips.29-31

Strong evidence supports the use of blunt-tip

suture needles for muscle and fascia closure. In

a Cochrane review of 10 randomized controlled

trials, researchers found that using blunt-tip suture

needles instead of sharp-tip suture needles re-

duced the incidence of glove perforation by 54%,

thereby reducing the risk of infectious disease

transmission.25

Managers can identify devices with engineering

controls through contact with vendors, attending

vendor displays at conferences, and professional

networking. A multidisciplinary committee in-

cluding direct users should be part of the process

for selecting and evaluating safety-engineered de-

vices.2 Educators can plan a product fair to help

personnel identify safety-engineered devices and

other sharps safety products to select for an eval-

uation. Perioperative RNs can encourage team

members to provide objective evaluations of safety-

engineered devices. After products are selected, the

educator may want to set up a sharps safety skills

fair to allow personnel and surgeons an opportunity

to have hands-on practice with the trial devices.

Recommendation III

Hand-to-hand passing of sharps, such as needles,

blades, and sharp instruments, accounts for the

majority of percutaneous injuries.3 Perioperative

personnel must use work practice controls when

handling any type of disposable or reusable sharp.

Work practice controls change the way a task

is performed when sharp devices are used. For

example, surgical team members should use a

neutral zone for passing any sharp device (eg,

blade, instrument, needle) rather than passing items

RP IMPLEMENTATION GUIDE: SHARPS SAFETY www.aornjournal.org

from hand to hand.14-17,29,32-37 A neutral zone helps

ensure that the surgeon and scrub person do not

touch the same sharp instrument at the same time.

This technique, also called hands-free technique,

is accomplished by designating a neutral zone on

the sterile field and placing sharp items within

the zone for transfer between scrubbed personnel.5

A modified neutral zone may be needed when

the surgeon is using a microscope; sharps are

carefully placed in the surgeon’s hand, and the

surgeon returns the sharp to the neutral zone after

use.14,33,38-42

The no-touch technique should be used to

minimize manual handling of sharps by gloved

hands. For example, when loading a suture in the

needle holder, the scrubbed team member should

keep the needle in the suture packet and use the

suture packet to position the needle in the needle

holder (Figure 2). The scrubbed team member

should then use a one-handed technique to reposi-

tion a needle before placing it in a needle box on

the sterile field.

Additional work control practices include main-

taining “situational awareness” when sharps are in

use, communicating the location of sharps on the

sterile field, removing needles before tying suture,

Figure 2. Use of the no-touch technique.

and using instruments instead of hands for tissue

retraction. Personnel should use caution at all times

when handling sharps and should follow safe in-

jection practices.11

To successfully implement work practice con-

trols, perioperative team members need to under-

stand potential hazards with a current practice, be

willing to change their practice, actually make the

practice change, and then consistently perform the

practice in the new, safer way. The importance of

education in this process cannot be understated.

Managers and educators can reinforce the princi-

ples of work practice controls and the importance

of communication and situational awareness during

use of sharps. The educator has a key role in pro-

viding assistance to individual team members and

surgical teams implementing work practice controls

and learning new ways to safely perform tasks.

Practice with the no-touch technique gives per-

sonnel the opportunity to try various ways of

manipulating sharps with minimal handling. Role

play and simulation activities can help team mem-

bers determine acceptable ways of implementing

use of a neutral zone for different surgical pro-

cedures and different patient positions. Periopera-

tive RNs and other team members can collaborate

with the educator to help personnel develop these

skills.

Recommendation IV

Proper use of PPE is required by the OSHA

Bloodborne Pathogens Standard.11 For example,

strong evidence exists to support the practice of

double gloving to reduce the risk of glove perfora-

tion and percutaneous exposure.43 In one study, the

overall perforation rate of gloves was 15.8%, which

presents concerns about bloodborne pathogen ex-

posure, breaks in sterile technique, and surgical site

infection.44 When two pairs of gloves are worn and

a perforation occurs, often only the outer glove is

perforated.43 Research has shown that if both gloves

are perforated, the volume of blood on a solid sharp

device can be reduced by as much as 95% compared

with perforation of a single glove.45-47

AORN Journal j 111

January 2014 Vol 99 No 1 FORD

Often, glove perforations are not detected by the

user. Use of a perforation indicator system (ie, a

colored glove under a standard glove) is recom-

mended for personnel wearing double gloves,

because perforations are easier to see and allow

detection more frequently (Figure 3).43 Gloves

should be monitored for punctures as a way to help

ensure barrier protection against transmission of

microorganisms and bloodborne pathogens to the

surgical field. Virus-inhibiting gloves, which re-

duce the amount of virus transmitted if a glove

becomes perforated, may be worn, especially dur-

ing procedures for which there is a higher risk of

glove perforation.48-50

Perioperative RNs should model the use of

standard precautions; wear appropriate PPE, in-

cluding protective eyewear, mask, and gloves; and

encourage other team members to wear PPE and

bloodborne pathogen protection. The RN circulator

also can help monitor scrubbed team members’

gloves for signs of perforation.43

Recommendation V

Safe handling of sharps includes ensuring that sharps

are contained in a safe manner and using proper

disposal practices. Sharps injuries can be sustained

Figure 3. Glove perforation of an outer glove withan inner indicator system glove. Reprinted withpermission from “Recommended practices for steriletechnique.” In: Perioperative Standards and Recom-mended Practices. Denver, CO: AORN, Inc; 2013:98.

112 j AORN Journal

because sharps are left on the floor or a table or are

protruding from a trash bag or disposal container.51

Sharps containers should be puncture and leak re-

sistant and large enough to hold the types of sharps

that will need to be placed in them.52 The container

should be recognizable, visible, and placed in prox-

imity to the point of use.52 After the container has

reached a visible fill level, the container should be

replaced.11 Personnel should use counting devices

to contain needles and sharps on the sterile field.11

Perioperative RNs can advocate for others

through careful use of sharps disposal containers,

such as by placing containers close to the point of

use, using care when putting sharps into the con-

tainer, and ensuring the containers are not overfilled.

Careful identification and separation of contami-

nated disposable and reusable sharps is important

to protect personnel in the decontamination area

from injury. Reusable sharps should be clearly se-

gregated on the case cart for easy identification.11

Recommendation VI

Perioperative RNs should maintain an awareness

of personal and professional responsibilities for

sharps injury prevention and serve as role models

for other team members. This includes observing

all local, state, and federal regulations pertaining to

handling of sharps and prevention of bloodborne

pathogens. Perioperative RNs can protect them-

selves by wearing appropriate PPE, getting immu-

nized against hepatitis B virus, using sharps devices

with safety features provided by the health care

facility, and complying with other policies and

procedures designed to protect against disease

transmission. If a perioperative RN sustains a

sharps injury, he or she should immediately report

the injury and receive prophylactic treatment for

bloodborne pathogen exposure. If a team member

experiences a sharps injury, the perioperative RN

can assist the team member with the reporting pro-

cess. Perioperative RNs can be leaders in the sharps

injury prevention process by being a “champion” of

sharps safety.

RP IMPLEMENTATION GUIDE: SHARPS SAFETY www.aornjournal.org

The Final Four

The final four recommendations in each AORN RP

document discuss education/competency, docu-

mentation, policies and procedures, and quality

assurance/performance improvement, as appli-

cable. These four topics are integral to the imple-

mentation of AORN practice recommendations.

Personnel should receive initial and ongoing edu-

cation and competency verification as applicable

to their roles. Implementing new and updated rec-

ommended practices affords an excellent opportu-

nity to create or update competency materials and

verification tools. AORN’s perioperative compe-

tencies team has developed the AORN Periopera-

tive Job Descriptions and Competency Evaluation

Tools53 to assist perioperative personnel in devel-

oping competency evaluation tools and position

descriptions.

Documentation is used as a method to monitor

compliance with regulations, measure performance

with sharps safety measures, maintain employee

records of education and competency verification,

and track occupational exposures. Implementing

Educational Resources

n AORN Video Library: Hand Hygiene, Gowning & Gloving

Practices in the Perioperative Setting [DVD]. http://cine-med.com/

index.php?nav¼aorn&cat¼all.

n AORN Video Library: Prevention of Transmissible Infections in

the Perioperative Practice Setting [DVD]. http://cine-med.com/

index.php?nav¼aorn&cat¼all.

n AORN Video Library: Risk Management for the Perioperative

Nurse [DVD]. http://cine-med.com/index.php?nav¼aorn&

cat¼all.

n Recommended practices for prevention of transmissible in-

fections in the perioperative practice setting. In: Perioperative

Standards and Recommended Practices. Denver, CO: AORN,

Inc; 2013:331-363.

n Sharps Safety Tool Kit. AORN, Inc. https://www.aorn.org/

Clinical_Practice/ToolKits/Tool_Kits.aspx.

Web site access verified November 1, 2013.

new or updated recom-

mended practices may war-

rant a review or revision of

the relevant documentation

being used in the facility.

Policies and procedures

should be developed, re-

viewed periodically, revised

as necessary, and readily

available in the practice

setting. New or updated

recommended practices

may present an opportunity

for collaborative efforts

among nurses and personnel

from other departments

in the facility to develop

organization-wide policies

and procedures that support

the recommended practices.

The AORN Policy and

Procedure Templates, 3rd edition,54 provides a

collection of 30 sample policies and customizable

templates based on AORN’s Perioperative Stan-

dards and Recommended Practices.55 Quality

assessment and improvement activities assist in

evaluating the quality of patient care, the presence

of environmental safety hazards, and the formula-

tion of plans for taking corrective actions. For details

on the final four practice recommendations that are

specific to the RP document discussed in this article,

please refer to the full text of the RP document.

AMBULATORY PATIENT SCENARIO

It is a busy day in a freestanding ambulatory sur-

gery center (ASC). The surgical team is finishing a

left knee arthroscopy on a 20-year-old male patient,

the third patient of six that day in the orthopedic

OR. The instrument table is moved away, and the

scrubbed team members remove the drapes. As the

RN circulator places a single hollow-bore needle

into the sharps container, the patient begins to wake

and move around. As the RN looks back to assist the

patient, she is stuck in the right index finger by a

AORN Journal j 113

January 2014 Vol 99 No 1 FORD

small-gauge K-wire that was removed from the first

patient of the day and is sticking out of the opening

in the sharps container.

After the patient is settled, the RN treats the

minor percutaneous injury. Knowing that she should

report the exposure, she considers the challenges.

The first patient of the day had undergone a pro-

cedure under a block anesthesia and moderate se-

dation and might already have been discharged

from the ASC; thus, obtaining a blood sample for

testing from the suspected source patient might not

be possible. If obtained, the blood sample would

have to be sent to a hospital laboratory in the vi-

cinity for processing. Also, the ASC contracts with

a hospital for occupational health services, so the

postexposure evaluation would be more difficult

and time consuming, requiring follow-up appoint-

ments at another facility. Because there are still

three more patients scheduled in her OR, the RN

knows it will be difficult to get away before the

schedule is completed, and she needs to hurry

home at the end of her shift to drive her daughter

to soccer practice.

Resources for Implementation

n AORN Syntegrity� Framework. AORN, Inc. htt

.org/syntegrity.

n ORNurseLinkTM. http://ornurselink.aorn.org.

n Perioperative Job Descriptions and Competency

Tools [CD-ROM]. Denver, CO: AORN, Inc; 201

www.aorn.org/JobDescriptions.

n Policy and Procedure Templates [CD-ROM]. 3rd

CO: AORN, Inc; 2013. http://www.aorn.org/Boo

cations/AORN_Publications/Policy_and_Procedu

.aspx.

n The Roadmap to ASC Compliance [CD-ROM]. D

AORN, Inc; 2012. http://www.aorn.org/Educatio

Ambulatory_Surgery_Center_Resources.aspx.

Editor’s note: Syntegrity is a registered trademark a

ORNurseLink is a trademark of AORN, Inc, Denver

Web site access verified November 1, 2013.

114 j AORN Journal

The RN also considers reasons she might not be

at risk for bloodborne pathogen exposure. She re-

ceived the hepatitis B vaccination, and because the

percutaneous injury was caused by a K-wire and not

a hollow-bore, blood-filled needle, she believes she

is at lower risk for acquiring hepatitis B, hepatitis

C, or HIV. Based on the patient’s age and medical

history, the RN makes the assessment that he was

probably at low risk for hepatitis C infection.

Despite these considerations, the RN knows it is

in her best interest to report the exposure as soon

as possible. In addition to concerns about her own

health, she is concerned about the health implications

for others in her family and possibly her patients as

well. Between scheduled surgeries, she contacts the

charge nurse and reports the exposure. The charge

nurse arranges relief for the RN so she can complete

the employee incident form and contacts the occu-

pational health nurse to report the exposure. The

suspected source patient has already been discharged

from the ASC, so the exposure is treated as an

“unknown source” exposure. Fortunately, her re-

sults are negative after one full year of testing.

p://www.aorn

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2. http://

ed. Denver,

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enver, CO:

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, CO.

HOSPITAL PATIENTSCENARIO

A 66-year-old woman with a

metastatic colon carcinoma

is undergoing an open left

hepatic lobectomy. The pa-

tient is obese and diabetic.

A certified surgical technol-

ogist (CST) in orientation

to the specialty is being

trained by another CST, so

both CSTs are scrubbed in.

During the procedure, the

patient has several periods

of hemodynamic instability

caused by bleeding. Thee

surgeon finishes repairing a

bleeding vessel and quickly

hands the cut suture with

needle back to the CST in

RP IMPLEMENTATION GUIDE: SHARPS SAFETY www.aornjournal.org

training. As the CST grasps the suture from the

surgeon’s hand, the needle perforates both layers

of the CST’s double gloves. The contaminated

needle is handed off to the RN circulator and the

experienced CST takes over until the patient’s

bleeding is controlled, allowing the CST in train-

ing to break scrub, treat the injury, and contact

the occupational health nurse on-call to report

the exposure. The postexposure evaluation is per-

formed, and blood is drawn from the patient. The

source patient is at low risk for bloodborne patho-

gens and, by being double gloved, the CST took

precautions to help prevent or reduce the risk of

bloodborne pathogen exposure. Her tests are ne-

gative for disease exposure.

Although an exposure control plan and sharps

safety program had been established at this hospital

in the early 1990s and modifications were made

annually, this and other percutaneous injury oc-

currences spur a renewed effort by the hospital

safety committee to bring sharps injury prevention

to the forefront. Educators plan a safety fair that is

held during a staff development session to show

various ways to minimize the risk of sharps in-

juries. Safety committee members present on the

topics of double gloving, using a neutral zone, and

handling sharps safely, as well as provide occupa-

tional exposure data. Later in the year, members of

the safety committee present a staff development

session in which they review the pertinent legisla-

tion, position statements from professional associ-

ations, and evidence-based recommendations. In

addition, the CST and another staff member who

had experienced recent percutaneous exposures

consent to tell the stories of their experiences.

This combination of topics helps reinforce the

current legislative requirements, what can be done

to minimize the risk of sharps injuries, and what

can happen when someone experiences an occu-

pational exposure from a sharps injury.

CONCLUSION

The AORN “Recommended practices for sharps

safety” is a thorough review of every aspect of

sharps injury prevention and associated evidence-

based recommendations. Key takeaways include

the following:

n Sharps injury prevention is a concern and a re-

sponsibility of all members of the perioperative

team.

n Knowing the causes and types of injuries that

occur in the practice setting is a critical com-

ponent of developing a sharps injury prevention

program.

n Prioritizing risk-reduction strategies involves

giving the highest priority to the device that

can have the greatest effect on sharps injury

reduction.

n Eliminating the hazard (eg, removing the sharp

object from use) and using safety-engineered

devices are the most effective ways to prevent

sharps injuries.

n Sharps injuries occur most frequently when

sharps are passed hand to hand, so scrubbed

team members should use a neutral zone.

n Double gloving minimizes the risk of blood-

borne pathogen exposure.

Perioperative RNs should be aware of methods

to prevent sharps injuries and occupational trans-

mission of bloodborne pathogens. The “Recom-

mended practices for sharps safety” delineates

how perioperative personnel should practice with-

in the recommendations. Perioperative nurses

should review the RP document with colleagues

and serve as a resource and role model for safe

sharps practices.

Acknowledgment: The author thanks Mary J. Ogg,

MSN, RN, CNOR, perioperative nursing specialist

at AORN, Inc, for her assistance with writing this

manuscript.

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care Worker Safety Center. University of Virginia Health

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epinet-2007-rates.pdf. Accessed October 16, 2013.

22. Thomas S, Agarwal M, Mehta G. Intraoperative glove

perforationdsingle versus double gloving in protection

against skin contamination. Postgrad Med J. 2001;

77(909):458-460.

23. Workbook for Designing, Implementing, and Evaluating a

Sharps Injury Prevention Program. Centers for Disease

Control and Prevention. http://www.cdc.gov/sharpssafety/

pdf/sharpsworkbook_2008.pdf. AccessedOctober 16, 2013.

24. Coulthard P, Esposito M, Worthington HV, van der

Elst M, van Waes OJ, Darcey J. Tissue adhesives for

closure of surgical incisions. Cochrane Database Syst

Rev. 2010;(5):CD004287.

25. Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt

versus sharp suture needles for preventing percutaneous

exposure incidents in surgical staff. Cochrane Database

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26. Nordkam RA, Bluyssen SJ, van Goor H. Randomized

clinical trial comparing blunt tapered and standard sur-

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27. Use of blunt-tip suture needles to decrease percutaneous

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cation No. 2008-101. 2008. http//www.cdc.gov/niosh/

docs/2008-101/pdfs/2008-101.pdf. Accessed October

16, 2013.

28. Miller SS, Sabharwal A. Subcuticular skin closure

using “blunt” needle. Ann R Coll Surg Engl. 1994;

76(4):281.

29. Dagi TF, Berguer R, Moore S, Reines HD. Preventable

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30. Makary MA, Pronovost PJ, Weiss ES, et al. Sharpless

surgery: a prospective study of the feasibility of per-

forming operations using non-sharp techniques in an

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31. Bhattacharyya M, Bradley H. Intraoperative handling and

wound healing of arthroscopic portal wounds: a clinical

study comparing nylon suture with would closure strips.

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32. Hidalgo JA, MacArthur RD, Crane LR. An overview of

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33. Folin A, Nyberg B, Nordstr€om G. Reducing blood ex-

posures during orthopedic surgical procedures. AORN J.

2000;71(3):573-582.

34. Jeong IS, Park S. Use of hands-free technique among

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Blythe J. Is use of the hands-free technique during sur-

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36. Stringer B, Haines T. The hands-free technique: an

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technique in the operating room: reduction in body fluid

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38. Bessinger CD Jr. Preventing transmission of human im-

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39. Stringer B, Infante-Rivard C, Hanley JA. Effective-

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40. Cunningham TR, Austin J. Using goal setting, task,

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free technique by hospital operating room staff. J Appl

Behav Anal. 2007;40(4):673-677.

41. Eggleston MK Jr, Wax JR, Philput C, Eggleston MH,

Weiss MI. Use of surgical pass trays to reduce intra-

operative glove perforations. J Matern Fetal Med. 1997;

6(4):245-247.

42. Stringer B, Haines T, Goldsmith CH, Blythe J, Harris KA.

Perioperative use of the hands-free technique: a semi-

structured interview study. AORN J. 2006;84(2):233-248.

43. Tanner J, Parkinson H. Double gloving to reduce surgical

cross-infection. Cochrane Database Syst Rev. 2002;(3):

CD0003087.

44. Ersozlu S, SahinO, Ozgur AF,Akkaya T, Tuncay C. Glove

punctures in major and minor orthopaedic surgery with

double gloving. Acta Orthop Belg. 2007;73(6):760-764.

45. Berguer R, Heller PJ. Preventing sharps injuries in the

operating room. J Am Coll Surg. 2004;199(3):462-467.

46. Aarnio P, Laine T. Glove perforation rate in vascular

surgeryda comparison between single and double

gloving. Vasa. 2001;30(2):122-124.

47. Laine T, Aarnio P. How often does glove perforation

occur in surgery? Comparison between single gloves

and a double gloving system. Am J Surg. 2001;181(6):

564-566.

48. Caillot JL, Voiglio EJ. First clinical study of a new virus-

inhibiting protective glove. Swiss Med Wkly. 2008;138

(1-2):18-22.

49. Krikorian R, Lozach-Perlant A, Ferrier-Rembert A, et al.

Standardization of needlestick injury and evaluation of

a novel virus-inhibiting protective glove. J Hosp Infect.

2007;66(4):339-345.

50. Bricout F, Moraillon A, Sonntag P, Hoerner P,

Blackwelder W, Plotkin S. Virus-inhibiting surgical

gloves to reduce the risk of infection by enveloped virus.

J Med Virol. 2003;69(4):538-545.

51. Grimmond T, Bylund S, Anglea C, et al. Sharps injury

reduction using a sharps container with enhanced en-

gineering: a 28 hospital nonrandomized intervention

and cohort sturdy. Am J Infect Control. 2010;38(10):

799-805.

52. Selecting, evaluating, and using sharps disposal containers.

NIOSH publication no. 97-111. 1988. National Institute for

Occupational Safety and Health. http://www.cdc.gov/niosh/

pdfs/97-111.pdf. Accessed November 1, 2013.

53. Perioperative Job Descriptions and Competency Evalu-

ation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012.

54. Policy and Procedure Templates. 3rd ed. [CD-ROM].

Denver, CO: AORN, Inc. 2013.

55. Perioperative Standards and Recommended Practices.

Denver, CO: AORN, Inc; 2013.

Donna A. Ford,MSN, RN-BC, CNOR, CRCST,

is a nursing education specialist, Division of

Surgical Services, Department of Nursing, Mayo

Clinic, and an assistant professor of nursing,

Mayo Clinic College of Medicine, Rochester,

MN. Ms Ford has no declared affiliation that

could be perceived as posing a potential conflict

of interest in the publication of this article.

This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon

which it is based and is not intended to be a replacement for that document. Individuals who are developing and

updating organizational policies and procedures should review and reference the full recommended practices

document.

AORN Journal j 117

EXAMINATION

CONTINUING EDUCATION

2.2

www.aorn.org/CEImplementing AORN Recommended

Practices for Sharps Safety

PURPOSE/GOAL

11

To provide the learner with knowledge specific to preventing sharps injuries and

bloodborne pathogen exposure.

OBJECTIVES

1. Discuss legislation related to preventing bloodborne pathogen transmission.

2. Discuss causes of percutaneous injury in perioperative settings.

3. Identify hazards associated with percutaneous injury.

4. Identify controls (ie, engineering, work practice, administrative) that can be used

to help prevent sharps injuries.

5. Describe actions perioperative RNs can take to assist in preventing sharps injuries

and bloodborne pathogen transmission.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE.

QUESTIONS

1. After passage of the Needlestick Safety and Preven-

tion Act, sharps injuries __________ in nonsurgical

settings and __________ in surgical settings.

a. decreased, decreased

b. decreased, increased

c. increased, decreased

d. increased, increased

2. An exposure control plan must include

1. a plan to reduce sharps injuries.

2. a process to monitor sharps injury data.

3. an exposure determination for employees who

may be exposed to blood and body fluids.

4. prioritized risk-reduction strategies.

8 j AORN Journal � January 2014 Vol 99 No 1

a. 1 and 4 b. 2 and 3

c. 1, 2, and 3 d. 1, 2, 3, and 4

3. The highest level of the hierarchy of controls to

help prevent sharps injuries is to

a. develop policies and procedures.

b. eliminate the hazard.

c. implement work practice controls.

d. use a safety-engineered device.

4. In a Cochrane review of 10 randomized controlled

trials, researchers found that using blunt-tip suture

needles instead of sharp-tip suture needles reduced

the incidence of glove perforation by

a. 10%. b. 32%.

c. 54%. d. 75%.

� AORN, Inc, 2014

CE EXAMINATION www.aornjournal.org

5. The majority of percutaneous injuries are caused by

a. failure to double glove.

b. hand-to-hand passing of sharps.

c. using sharp-tip rather than blunt-tip needles.

d. using safety-engineered devices.

6. Use of a neutral zone helps ensure the surgeon

and scrub person do not touch the same instru-

ment at the same time.

a. true b. false

7. Communicating the location of sharps on the

sterile field is

a. an administrative control.

b. an engineering control.

c. a work practice control.

8. Personnel may choose to wear virus-inhibiting

gloves during procedures in which there is a

higher risk of glove perforation.

a. true b. false

9. A sharps container should be

1. large enough to hold the types of sharps that

will need to be placed in them.

2. placed far from the point of use to prevent

accidental contact with the container.

3. puncture and leak resistant.

4. replaced when it reaches a visible fill level.

a. 1 and 3 b. 2 and 4

c. 1, 3, and 4 d. 1, 2, 3, and 4

10. Perioperative RNs can demonstrate personal and

professional responsibility in preventing sharps

injuries and bloodborne pathogen transmission by

1. getting immunized against hepatitis B virus.

2. immediately reporting a percutaneous injury.

3. observing local, state, and federal regulations

pertaining to handling of sharps.

4. receiving prophylactic treatment for blood-

borne pathogen exposure when necessary.

a. 1 and 2 b. 3 and 4

c. 2, 3, and 4 d. 1, 2, 3, and 4

AORN Journal j 119

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

2.2

www.aorn.org/CEImplementing AORN Recommended

Practices for Sharps Safety

This evaluation is used to determine the extent

to which this continuing education program met

your learning needs. The evaluation is printed

here for your convenience. To receive continuing

education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Discuss legislation related to preventing bloodborne

pathogen transmission.

Low 1. 2. 3. 4. 5. High

2. Discuss causes of percutaneous injury in periopera-

tive settings. Low 1. 2. 3. 4. 5. High

3. Identify hazards associated with percutaneous injury.

Low 1. 2. 3. 4. 5. High

4. Identify controls (ie, engineering, work practice,

administrative) that can be used to help prevent

sharps injuries.

Low 1. 2. 3. 4. 5. High

5. Describe actions perioperative RNs can take to assist

in preventing sharps injuries and bloodborne path-

ogen transmission.

Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

120 j AORN Journal � January 2014 Vol 99 No 1

8. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of

reading this article? (If yes, answer question

#9A. If no, answer question #9B.)

9A. How will you change your practice? (Select all that

apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: _______________________________

9B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others about

the purpose of the needed change.

3. I do not have management support to make a

change.

4. Other: ________________________________

10. Our accrediting body requires that we verify

the time you needed to complete the 2.2 con-

tinuing education contact hour (132-minute)

program: _________________________________

� AORN, Inc, 2014