JECSONS MEDICAL CENTER

Department of Nursing INTERNAL POLICIES AND/OR PROCEDURE (IPP)

TITLE/DESCRIPTION: DOCUMENT NUMBER:
PREVENTION & MANAGEMENT OF NEEDLESTICK INJURIES JMC-DON-001-2017
EFFECTIVE DATE: REPLACES NUMBER: APPLIES TO: APPROVED BY:

JULY 2017 NA Nurses Signature on File

Medical Director

PURPOSE
To ensure all sharps/needles are risk assessed in order to reduce the risk of exposure to blood borne
infections following needlestick injuries

DEFINITION
Prevention of blood borne infection secondary to needlestick injuries and promotion of awareness of
healthcare workers in the safe handling of sharps

EQUIPMENT/SUPPLIES
1. Pen
2. Record book
3. Incident report form
4. Consent form
REFERENCES
https://www.bd.com/tr/safety/hcws_docs/Risk_Assessment.pdf
https://patient.info/doctor/needlestick-injury-pro

Form JMC DON 001-2017 Page 1 of 5

 JECSONS MEDICAL CENTER
Department of Nursing INTERNAL POLICIES AND/OR PROCEDURE (IPP)
TITLE/DESCRIPTION: DOCUMENT NUMBER:
PREVENTION & MANAGEMENT OF NEEDLESTICK INJURIES JMC-DON-001-2017
EFFECTIVE DATE: REPLACES NUMBER: APPLIES TO: APPROVED BY:

JULY 2017 NA Nurses Signature on File

Medical Director

POLICIES:

All staff who undertake work which requires them to use sharps should:

1. Ensure that working practices be regularly reviewed to eliminate the use of unnecessary
sharps;
2. Always ensure the correct device has been selected for the task, and ensure as far as
practicable that a sharp with a safety device is selected for use;
3. Always ensure that a sharp safe box/container is available to dispose of any sharp at the
point of use;
4. Never start a procedure without having a facility available to dispose of sharps;
5. Never re-sheath needles;
6. Never allow sharps boxes to become more than two thirds full;
7. Never shake the sharps box contents down. Sharps can fly out of the box causing injury;
8. Never leave a used needle or blade unattended. Always dispose of your equipment safely,
before undertaking another task;
9. If you find a sharp/needle in an inappropriate place, always take extra care. Pick up the
sharp with forceps, or gently scoop into a dustpan using a brush and place into the nearest
sharps box. Report the incident to your Supervisor or Infection Control Nurse;
10. It is the user’s responsibility to dispose of used sharps as soon as possible after use.

Following a needle stick injury the following should be applied:

1. The recipient of the Needle stick injury should contact the Infection Control
Nurse/Committee immediately between 8am-5pm weekdays or Nurse Supervisor on Duty
outside of these hours for immediate advice and follow up.
2. Blood tests for blood borne viruses should be followed up urgently. The recipient must be
informed of the results of any blood tests.

SPECIFIC ROLES AND RESPONSIBILITIES

8AM - 5 PM WEEKDAYS

Recipient
1. Inform nurse in charge of clinical area.
2. Complete incident report form.

Form JMC DON 001-2017 Page 2 of 5

 JECSONS MEDICAL CENTER
Department of Nursing INTERNAL POLICIES AND/OR PROCEDURE (IPP)
TITLE/DESCRIPTION: DOCUMENT NUMBER:
PREVENTION & MANAGEMENT OF NEEDLESTICK INJURIES JMC-DON-001-2017
EFFECTIVE DATE: REPLACES NUMBER: APPLIES TO: APPROVED BY:

JULY 2017 NA Nurses Signature on File

Medical Director

Nurse in Charge (Infection Control Nurse)

1. Ensure protocol is followed and incident form completed.
2. Release staff member from work for immediate follow up.

Resident Doctor on call

1. Perform assessment of patient.
2. Consent donor for HIV/HBV and HCV antibody tests, if unable to consent e.g. donor
unconscious, contact Consultant on-call.
3. Take blood from donor or needlestick injury, send to Jecsons Laboratory urgently,
marked needlestick injury donor and indicate on form that consent was obtained.
4. Phone Laboratory Department to advise of laboratory request.

5PM - 8 AM AND WEEKENDS/ HOLIDAYS

Recipient
1. Contact nurse in charge of clinical area (Nurse Supervisor on duty)
2. Fill in incident form and report injury to infection Control Nurse during next office
hours.

Nurse in charge of clinical area (Nurse Supervisor on duty)

1. Inform Medical Resident on-call.
2. Ensure protocol is followed and incident form completed.

Resident Doctor on call

1. Assessment of patient.
2. Consent donor for HIV/HBV and HCV antibody tests.
3. Take blood from donor or needlestick injury, send to Jecsons Laboratory urgently,
marked needlestick injury donor and indicate on form that consent was obtained.
4. Phone Laboratory Department to advise of lab request.
5. 5. If high risk needlestick injury or in any doubt contact Infectious Disease physician on
call for further evaluation and management.

Form JMC DON 001-2017 Page 3 of 5

 JECSONS MEDICAL CENTER
Department of Nursing INTERNAL POLICIES AND/OR PROCEDURE (IPP)
TITLE/DESCRIPTION: DOCUMENT NUMBER:
PREVENTION & MANAGEMENT OF NEEDLESTICK INJURIES JMC-DON-001-2017
EFFECTIVE DATE: REPLACES NUMBER: APPLIES TO: APPROVED BY:

JULY 2017 NA Nurses Signature on File

Medical Director

PROCEDURE:

1. Following a needle stick injury, immediately stop what you are doing and attend to
the injury.
2. Make the wound bleed, if possible. Do not suck.
3. Wash the area with running water for 30 seconds, dry and apply dressing as
necessary.
4. Inform the nurse supervisor/infection control nurse.
5. Complete the Incident Report Form. Incident report must be completed with the
following details:
5.1The source of the Sharp and description of the accident, including the place,
date, time and any witnesses.
5.2 The name of the source patient.
5.3 The action taken.
5.4 Any person who gave advice and the advice given.
5.5 The advice given to the patient and / or staff member concerned.
5.6 The action taken to prevent recurrence.
6. Initiate investigation as to the case of incident.
6.1 Injury from clean needle or instrument - No further action likely
6.2 Injury from used needle or instrument
- Report/Assess/Investigate/Management

Reporting and Management of Needlestick Injuries

1. Identify the patient and the member of staff affected.

2. Take a focused history to identify risk of HIV, HEP B (HBV) and HEP C (HCV). Note the
type of injury, depth, gauge of needle, if used for injecting or aspiration, and if hollow
bore or bloodstained.
3. Take blood - in particular: HIV, Hep B, Hep C. Counsel and consent patient and
member of staff that blood will be tested for HIV, Hep B and Hep C.
4. If high risk for HIV: start Post Exposure Prophylaxis (preferably within an hour, but
worthwhile up to 36 hours post-exposure).
5. Find HBV status of “recipient” and consider booster even if good immunity, consider
HEP B immunoglobulins. If immunoglobulin is required, the member of staff will be
contacted and treated by the Accident and Emergency Unit. Immunoglobulin must be
given within 48 hours to be of most benefit.

Form JMC DON 001-2017 Page 4 of 5

 JECSONS MEDICAL CENTER
Department of Nursing INTERNAL POLICIES AND/OR PROCEDURE (IPP)
TITLE/DESCRIPTION: DOCUMENT NUMBER:
PREVENTION & MANAGEMENT OF NEEDLESTICK INJURIES JMC-DON-001-2017
EFFECTIVE DATE: REPLACES NUMBER: APPLIES TO: APPROVED BY:

JULY 2017 NA Nurses Signature on File

Medical Director

6. Repeat blood tests will be needed in 3 months time from both patient and member of
staff who counseled them. HIV testing is not routine and will not be undertaken
without full counseling.
7. An incident report should be completed. Also notify Infection Control
Nurse/Supervisor of the incident with details for follow up.

PREPARED BY:

Carmella Eunice G. Manlutac, RN

Infection Control Nurse

Marie Alfia Lou C. Valdez, RN, MSN

Assistant Training Officer

Fernando R. Aquino, RN, PhD

Chief Nurse

APPROVED BY:

Jose Y. Chua, Jr., MD, FPCS, FPSGS

Medical Director

Form JMC DON 001-2017 Page 5 of 5