Needlestick & Sharp Object Injury Report/OR

Last name: ______First name: ______

Injury ID:(for office use only) S______Facility ID: (for office use only) ______ Completed by: ______

1.Date of injury:2.Time of injury:

3.Surgical service:

1General6ENT11Transplants

2Cardiovascular7Neurosurgery12Ophthalmology

3OB/C-section8Plastic13Thoracic

4Gynecology9Urology

5Orthopedic10Oral/Dental99Other service, describe: ______

4. Surgical procedure being performed: ______

4a.Was it an endoscopic/laparascopic procedure?

1Yes2No3Unknown4Not applicable

5.What is the job category of the injured worker? (check one box only)

1Surgeon (attending) specify specialty ______9Circulating nurse at time of incident →1 RN2 ORT3 UAP

2Surgeon (resident) specify specialty ______10Scrub nurse at time of incident →1 RN2 ORT3 UAP

3Ob/Gyn (attending)11Other Nurse

4Ob/Gyn (resident)12Nursing student

5Anesthesiologist (attending)13OR attendant

6Anesthesiologist (resident)14Housekeeper

7Nurse anesthetist

8Med student, mark rotation→surganesthob-gyn99Other, describe: ______

5a.If the injury was sustained by an anesthesia team member, what anesthesia task was being performed at the time of exposure?

describe: ______

6.Where did the injury occur? (check one box only)

1Pre-operative area8At patient’s puncture site (intro of vascular cath/injection,etc)

2At the mayo (instrument) stand9At site of injection into IV equipment

3At the back table10on OR floor

4In the operative site/wound11in the OR utility room

5On the surgical field (near operative site)12Post anesthesia care unit (recovery room)

6On anesthesia machine

7On anesthesia cart99Other, describe: ______

7.Was the source patient’s identity known? (check one box only)

1Yes2No3Unknown4Not applicable

8.For what purpose was the sharp item originally used? (check one box only)

1Unknown/not applicable12Cutting (surgery)

2Injection, intra-muscular/subcutaneous, or other injection13Suturing muscle/fascia

through the skin (syringe)14Suturing skin

3To start IV or set up heparin lock (IV catheter or winged set- 21Suturing tissue not listed above, describe: ______

type needle)15Electrocautery

4To connect IV line (intermittent IV/piggyback/IV infusion/other16Drilling/sawing

IV line connection)17Retracting tissue/bone

5Injection into (or aspiration from) IV injection site or IV port18Wiring/fixing

6To place an arterial line/catheter19Using as a tool, not on patient

7To place a central line/catheter20To contain a specimen or pharmaceutical (glass items)

8To place other non-vascular line/catheter99Other; describe ______

9To draw venous blood sample ════╗

10To draw arterial blood sample ════╩►ifused to draw blood was it? 1Direct stick?2Drawn from a line?

11To obtain a body fluid or tissue sample(urine/CSF/amniotic fluid/other fluid, biopsy)

9.Did the injury occur? (check one box only)

1Before use of item (item broke/slipped, assembling device, etc.)12Withdrawing needle from rubber or resistant material

2During use of item (item slipped, patient/colleague jarred item, etc)13Other after use-before disposal (in transit to trash, cleaning,

3While manually retracting tissue in operative siteleft on bed, table, floor, or other inappropriate place, etc.)

4While retracting tissue using retractor or other instrument14From item left on or near disposal container

5Passing instruments, hand-to-hand15While putting item into disposal container

6Passing instruments, hand-free transfer16After disposal, stuck by item protruding from opening of

7Between incremental injectionsdisposal container

8In between uses of devices17Item pierced side of disposal container

9Disassembling device or equipment18After disposal, item protruded from trash bag or

10Sorting, disinfecting, and/or sterilizing instrumentsinappropriate waste container

11While recapping a used needle99Other, describe: ______

10.At the time of the injury, was the sharp instrument/item? (check one box only)

1Held by another person2Held by injured person3Not held by anyone

11.The sharp item was: (check one box only)

1Contaminated (known exposure to patient or contaminated equipment) ═══►was there blood on the device?1Yes

2Uncontaminated (no known exposure to patient or contaminated equipment)2No

3Unknown

12.What type of device caused the injury? (check one box only)Needle-Hollow Bore

Surgical  Glass4

Which device caused the injury? (check one box from one of the three sections only)

Needles (for suture needles see “surgical instruments”)

1Disposable Syringe (includes standard, insulin, tuberculin, etc)9Spinal or epidural needle

2Pre-filled cartridge syringe (includes Tubex™ *, Carpuject ™* -10Unattached hypodermic needle

type syringes)11Arterial catheter introducer needle

3Blood gas syringe (ABG)12Central line catheter introducer needle

4Syringe, other type13Drum catheter needle

5Needle on IV line (includes piggybacks & IV line connectors)14Other vascular catheter needle (cardiac etc.)

6Winged steel needle (includes winged-set type devices)15Other non-vascular catheter needle (ophthalmology, etc.)

7IV catheter stylet16Huber-type needle

8Vacuum tube blood collection holder/needle (includes28Needle, not sure what kind

Vacutainer™ *–type device)29Other needle: describe: ______

Surgical instrument or other sharp items(for glass items see “glass”)

30Lancet (finger or heel sticks)40Microtome blade

31Suture needle41Trocar

32Scalpel blade, reusable handle42Vacuum tube (plastic)

45Scalpel blade, disposable handle43Specimen/Test tube (plastic)

33Razor44Fingernails/Teeth

34Pipette (plastic)46Retractors, skin/bone hooks

35Scissors47Staples/Steel sutures

360Electro-cautery device, needle tip48Wire (suture/fixation/guide wire)

361Electro-cautery device, blade tip49Pin (fixation, guide pin)

362Electro-cautery device, loop tip50Drill bit/burr

37Bone cutter51Pickups/Forceps/Hemostats/Clamps

38Bone chip58Sharp item, not sure what kind

39Perforating towel clip59 Other sharp item: describe: ______

Glass

60Medication ampule65Specimen/Test tube (glass)

61Medication vial (small volume with rubber stopper)66Capillary tube

62Medication/IV bottle (large volume)67Glass slide

63Pipette (glass)78Glass item, not sure what kind

64Vacuum tube (glass)79Other glass item: describe: ______

12a.Brand/Manufacturer of product: (e.g. ABC Medical Company) ______

12b.Model:98Known: Please specify: ______99Unknown

13.If the item causing the injury was a needle or sharp medical device, was it a” safety design” with a shielded, recessed, retractable,

or blunted needle or blade?1Yes2No3Unknown

13a.Was the protective mechanism activated?1Yes, fully2Yes, partially3No4Unknown

13b.Didthe injury happen?1Before activation2During activation3After activation4Unknown

14.Mark the location of the injury:══╗

15.Was the injury?

1Superficial (little or no bleeding)

2Moderate (skin punctured, some bleeding)

3Severe (deep stick/cut, or profuse bleeding)

16.If injury was to the hand, did the sharp item penetrate?

1Single pair of gloves2Double pair of gloves3No gloves

17.Dominant hand of the injured worker:1Right-handed2Left-handed

18.Describe the circumstances leading to this injury (please note if a device malfunction was involved):

______

19.For injured healthcare worker: If the sharp had no integral safety feature, do you have an opinion that such a feature could have prevented thisinjury?  1 Yes  2 No  3 Unknown

describe: ______

______

20.For injured healthcare worker: Do you have an opinion that any other engineering control, administrative or work practice could have prevented this injury?  1 Yes  2 No  3 Unknown

describe: ______

______

Cost:

Lab charges (Hb, HCV, HIV, other)

______Healthcare worker

______Source

Treatment prophylaxis (HBIG, Hb vaccine, tetanus, other)

______Healthcare worker

______Source

______Service charges (Emergency Dept, Employee Health, other)

______Other costs (Worker’s Comp, surgery, other)

______TOTAL (round to nearest dollar)

Is this incident OSHA reportable?1Yes2No3Unknown

If yes, days away from work? _____

Days of restricted work activity? _____

Does this incident meet the FDA medical device reporting criteria? (Yes if a device defect caused serious injury necessitating medical or surgical intervention, or death occurred within 10 works days of incident.)

1Yes (If yes, follow FDA reporting protocol.)2No3Unknown

* Tubex™ is a trademark of Wyeth Ayers; Carpuject™ is a trademark of Sanofi Winthrop; VACUTAINER™ is a trademark of Becton Dickinson. Identification of these products does not imply endorsement of these specific brands.

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