Use this SOP to ensure prompt care, confidential reporting, complete injury documentation, and required OSHA recordkeeping after every occupational sharps exposure.

šŸ“š Resources Needed

  • Besa Healthā€™s written post-exposure protocol for occupational exposure to blood or body fluids, including percutaneous injury

  • The Sharps Injury Incident Report Google Form for one confidential response per exposure incident

  • OSHA Form 300, Log of Work-Related Injuries and Illnesses

  • OSHA Form 301, Injury and Illness Incident Report, or an equivalent form

  • A confidential designated recordkeeping location, such as occupational health or infection control

  • Access to prompt medical evaluation and treatment during all work hours

  • A trained team member who can coordinate baseline testing, source-patient follow-up, and record retention

Incident Report Form: Sharps Injury Incident Report

āœ… Before You Start

  • All personnel responsible for treating bloodborne-pathogen exposures must be trained in the facilityā€™s post-exposure protocol.

  • Training must cover which baseline tests to conduct, whom to contact for source-patient follow-up, and where confidential records are maintained.

  • The protocol must tell employees where and how to obtain medical evaluation and treatment after occupational exposure to blood or body fluids, including a percutaneous injury.

  • The protocol must encourage prompt reporting and allow rapid medical care during all work hours.

  • The reporting system must protect the confidentiality of exposed employees and exposed non-employees, including students, per diem staff, and volunteers.

šŸš€ Tips & Tricks

  • Keep the incident-report link readily available to supervisors and clinical personnel.

  • Assign a unique incident identification number without placing the injured personā€™s name on any log that must preserve confidentiality.

  • Complete the report while the facts are fresh, but do not delay immediate medical evaluation or treatment to complete documentation.

  • Use the same incident identification number to connect related internal, OSHA 300, OSHA 301, and follow-up records without exposing the workerā€™s identity on the sharps log.

šŸ“˜ Instructions

Step 1: Report The Exposure Promptly

  • Immediately report every occupational exposure to blood or body fluids, including needlesticks, cuts from sharps, and other percutaneous injuries, according to Besa Healthā€™s post-exposure protocol.

  • Do not delay reporting. Prompt reporting supports rapid medical evaluation and treatment.

Step 2: Obtain Medical Evaluation And Treatment

  • Direct the exposed person to the location identified in the post-exposure protocol for medical evaluation and treatment.

  • Ensure rapid access to medical care during all work hours.

  • Follow the trained post-exposure process for required baseline tests and source-patient follow-up.

  • Continue follow-up according to the evaluating clinicianā€™s instructions and the facilityā€™s post-exposure protocol.

Step 3: Create A Confidential Incident Record

  • Complete one Sharps Injury Incident Report Google Form response for each employee or non-employee exposure incident involving a sharp.

  • Assign a unique incident identification number. Maintain records in a way that protects the confidentiality of the healthcare worker.

  • Store exposure reports in the designated confidential area, such as occupational health or infection control, for follow-up and recordkeeping.

Step 4: Record The Required Minimum Data

  • Unique incident identification number

  • Date and time of the injury

  • Occupation or job classification of the worker

  • Department or work area where the exposure incident occurred

  • Type of device involved in the injury

  • Presence or absence of an engineered sharps-injury prevention feature on the device

  • Brand of the device

  • Purpose or procedure for which the sharp device was being used

  • When and how the injury occurred

Step 5: Complete The Detailed Incident Investigation

  • Document the institution, department, address, city, state, ZIP code, date completed, person completing the report, and phone number.

  • Document the injury date and time, optional age and sex, a complete description of the exposure incident, job classification, and department or location.

  • Identify the procedure being performed and the point in the procedure when the exposure occurred.

  • Identify every affected body part and record the sharpā€™s type, brand, and model when known.

  • Record whether the device had engineered sharps-injury protection, whether the protective mechanism was activated fully or partially, and whether the exposure occurred before, during, or after activation.

  • Ask whether an engineered sharps-injury prevention mechanism could have prevented the injury and document the explanation.

  • Ask whether any other engineering, administrative, or work-practice control could have prevented the injury and document the explanation.

Step 6: Determine Whether OSHA Recording Is Required

  • Record every work-related needlestick injury or cut from a sharp object contaminated with another personā€™s blood or other potentially infectious material, as defined by 29 CFR 1910.1030.

  • Enter each applicable case on the OSHA 300 Log as an injury.

  • Complete an OSHA 301 Incident Report or an equivalent form for each recordable injury or illness entered on the OSHA 300 Log.

Step 7: Meet The Seven-Day Deadline

  • Enter each recordable injury or illness on the OSHA 300 Log and OSHA 301 Incident Report, or equivalent form, within seven calendar days after receiving information that the recordable injury or illness occurred.

  • Escalate immediately if the seven-day deadline may be missed.

Step 8: Maintain The Sharps Injury Log When Required

  • If the practice has 10 or more employees, maintain a sharps injury log for injuries from contaminated sharps.

  • At minimum, the sharps injury log must describe the injury, the type and brand of device involved if known, the work area where the exposure occurred, and an explanation of how the incident occurred.

  • Maintain the log in a way that protects the confidentiality of the injured employee.

Step 9: Retain Records For Follow-Up And Prevention Planning

  • Keep exposure reports in the designated confidential recordkeeping location for follow-up and required retention.

  • Use aggregated incident information to identify patterns and improve sharps-injury prevention planning without disclosing an injured personā€™s identity.

šŸ›  Troubleshooting

The Injured Person Is Not A Regular Employee

Use the same prompt reporting, medical-evaluation, treatment, confidentiality, and documentation process for students, per diem staff, volunteers, and other exposed non-employees.

The Device Type Or Brand Is Unknown

Document that it is unknown. Do not guess. Record every other available fact, including the work area, procedure, and explanation of how the incident occurred.

The Incident Report Is Incomplete

Return to the exposed person and supervisor promptly to obtain missing facts. Do not delay medical evaluation or treatment while completing the record.

The Seven-Day OSHA Deadline Is Approaching

Escalate to the person responsible for OSHA recordkeeping and complete the OSHA 300 and OSHA 301 or equivalent entries before the deadline.

A Confidentiality Concern Is Identified

Restrict access and move the record to the designated confidential location. Use the unique incident identification number on sharps logs and prevention summaries.

āœ… Completion Check

Confirm every item before closing the incident:

  • The exposure was reported promptly and medical evaluation and treatment were made available during work hours.

  • Required baseline testing and source-patient follow-up were coordinated by trained personnel.

  • One Sharps Injury Incident Report response was completed for the exposure incident.

  • A unique incident identification number was assigned and confidentiality was protected.

  • All minimum data elements and detailed page 233 incident fields were documented or marked unknown or not applicable when appropriate.

  • Every recordable contaminated-sharps injury was entered on the OSHA 300 Log as an injury.

  • An OSHA 301 Incident Report or equivalent form was completed for each case entered on the OSHA 300 Log.

  • OSHA 300 and 301 or equivalent entries were completed within seven calendar days of receiving the information.

  • If the practice has 10 or more employees, the confidential sharps injury log was updated with the required details.

  • Exposure records were stored in the designated confidential location for follow-up and recordkeeping.

References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Sharps Injury Control Program, pages 231ā€“232; Sharps Injury Log, page 233

Source Protocol Revision: July 7, 2020

OSHA: Recordkeeping Forms

OSHA: 29 CFR 1904.29 Forms

OSHA: 29 CFR 1910.1030 Bloodborne Pathogens

CDC: Sharps Safety Program Resources

Internal readiness SOP only; the full CalOptima, OSHA, CDC, and applicable workplace-safety requirements control.