Needlestick & Sharp Object Injury Report

Send completed form to the West Virginia Needlestick Injury Prevention Program,

350 Capitol Street, Room 125, Charleston, WV 25301 or fax to (304) 558-4744.

Phone: (304) 558-2195

Facility Code: / Submitted By:
Facility Name:

Incident ID: (for WVNIPP office use only)S______

1) Date of Injury: / 2) Time of Injury:
(24-hour format)

5)What is theJob Category of the Injured Worker: (check one box only)

1Doctor (attending/staff); specify specialty ______10Clinical Laboratory Worker

2Doctor (intern/resident/fellow) specify specialty ______11Technologist (non-lab)

3Medical Student12Dentist

4Nurse: specify ═════►1RN13Dental Hygienist

5Nursing Student2 LPN14Housekeeper

18CNA/HHA3NP19Laundry Worker

6Respiratory Therapist4CRNA20Security

7Surgery Attendant5Midwife 16Paramedic

8Other Attendant17Other Student

9Phlebotomist/Venipuncture/IV Team15Other, describe: ______

6)Where Did the Injury Occur? (check one box only)

1Patient Room9Dialysis Facility (hemodialysis and peritoneal dialysis)

2Outside Patient Room (hallway, nurses station, etc.)10Procedure Room (x-ray, EKG,etc)

3Emergency Department11Clinical Laboratories

4Intensive/Critical Care unit: specify type: ______12Autopsy/Pathology

5Operating Room/Recovery13Service/Utility (laundry,central supply,loading dock,etc)

6Outpatient Clinic/Office16Labor and Delivery Room

7Blood Bank17Home-care

8Venipuncture Center14Other, describe: ______

7) Was the Source Patient Identifiable? (check one box only)

1Yes2No3Unknown4Not Applicable

8)Was the Injured Worker the Original User of the Sharp Item? (check one box only)

1Yes2No3Unknown4Not Applicable

9)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

10)For What Purpose was the Sharp Item Originally Used? (check one box only)

1Unknown/Not Applicable16To Place an Arterial /Central Line

2Injection, Intra-muscular/Subcutaneous, or Other Injection9To Obtain a Body Fluid or Tissue Sample

through the Skin (syringe)(urine/CSF/amniotic fluid/other fluid, biopsy)

3Heparin or Saline Flush (syringe)10Finger stick/Heel Stick

4Other Injection into (or aspiration from) IV injection site or11Suturing

IV Port (syringe)12Cutting

5To Connect IV line (intermittent IV/piggyback/IV infusion/other17Drilling

IV line connection)13Electrocautery

6To Start IV or Set up Heparin Lock (IV catheter or winged set-14To Contain a Specimen or Pharmaceutical (glass item)

type needle)15Other; Describe ______

7To Draw Venous Blood Sample ════╗

8To Draw Arterial Blood Sample ════╩►ifused to draw blood was it?Direct stick? Draw from a Line?

11)Did the Injury Occur? (check one box only)

1Before Use of Item (item broke/slipped, assembling device, etc.)16Device Left on Floor, Table, Bed or Other Inappropriate Place

2During Use of Item (item slipped, patient jarred item, etc)8Other After Use-Before Disposal (in transit to trash, cleaning,

15Restraining patientsorting, etc.)

3Between Steps of a Multi-step Procedure (between incremental9From Item Left On or Near Disposal Container

injections, passing instruments, etc.)10While putting Item into Disposal Container

4Disassembling Device or Equipment11After Disposal, Stuck by Item Protruding from Opening of

5In Preparation for Reuse of Reusable Instrument (sorting, disin-Disposal Container

fecting, sterilizing, etc.)12Item Pierced Side of Disposal Container

6While Recapping Used Needle13After Disposal, Item Protruded from Trash Bag or

7Withdrawing a Needle from Rubber or Other Resistant MaterialInappropriate Waste Container

(rubber stopper, IV port, etc.)14Other: Describe: ______

12)What Type of Device Caused the Injury? (check one box only)Needle-Hollow Bore

Surgical  Glass

Which Device Caused the Injury? (check one box from one of the three sections only)

Needles (for suture needles see “surgical instruments”)

1Disposable Syringe8Vacuum tube blood collection holder/needle (includes

aInsuline22-gauge needleVacutainer™ *–type device)

bTuberculinf21-gauge needle9Spinal or Epidural Needle

c24/25-gauge needleg20-gauge needle10Unattached hypodermic needle

d23-gauge needleh“Other”11Arterial catheter introducer needle

2Pre-filled cartridge syringe (includes Tubex™ *, Carpuject ™* -12Central line catheter needle (cardiac, etc.)

type syringes)13Drum catheter needle

3Blood gas syringe (ABG)14Other vascular catheter needle (cardiac, etc.)

4Syringe, other type15Other non-vascular catheter needle (ophthalmology, etc.)

5Needle on IV line (includes piggybacks & IV line connectors)

6Winged steel needle (includes winged-set type devices)28Needle, not sure what kind

7IV catheter stylet29Other needle, please describe: ______

Surgical Instrument or Other Sharp Items(for glass items see “glass”)

30Lancet (finger or heel sticks)43Specimen/Test tube (plastic)

31Suture needle44Fingernails/Teeth

32Scalpel, reusable (scalpel, disposable code is 45)45Scalpel, disposable

33Razor46Retractors, skin/bone hooks

34Pipette (plastic)47Staples/Steel sutures

35Scissors48Wire (suture/fixation/guide wire

36Electro-cautery device49Pin (fixation, guide pin)

37Bone cutter50Drill bit/bur

38Bone chip51Pickups/Forceps/Hemostats/Clamps

39Towel clip

40Microtome blade

41Trocar58Sharp item, not sure what kind

42Vacuum tube (plastic)59 Other sharp item: Describe: ______

Glass

60Medication ampule66Capillary tube

61Medication vial (small volume with rubber stopper)67Glass slide

62Medication/IV bottle (large volume)

63Pipette (glass)

64Vacuum tube (glass)78Glass item, not sure what kind

65Specimen/Test tube (glass)79Other glass item: Describe: ______

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

12b)Model:

98Please Specify: ______99Unknown

13)If the Item Causing the Injury was a Needle or Sharp13a)Was the Protective Mechanism Activated?

Medical Device, Was it a” Safety Design” with a Shielded,1Yes, fully3No

Recessed,Retractable, or Blunted Needle or Blade?2Yes, partially4Unknown

1Yes

2No13b)Did Exposure Incident Happen?

3Unknown1Before activation3After activation

2During 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 the Injury?  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 the Injury?  1 Yes  2 No  3 Unknown

Describe:

* 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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