Management & Safety of Sharps Policy
Version: V6
Ratified by:
Infection Prevention and Control Group
Date ratified: 18/06/2025
Job Title of author: Head of Infection Prevention & Control
Reviewed by Committee or Expert Group
Infection Prevention and Control Group
Equality Impact Assessed by: Head of Infection Prevention & Control
Related procedural documents
HSPOL26 Medical Devices Policy and Procedure
IPPOL09 Decontamination of Medical Devices
EPOL05 Healthcare Waste Policy
IPPOL21 Policy for Standard Precautions for Infection Prevention
HSPOL08 Health and Safety Policy
IPPOL14 Management of Exposure to Blood Borne Viruses Policy
Review date: 18/06/2028
It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet
In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.
Version Control Sheet
Version Date
Author Status Comment
V1 April2011 Head of Infection Prevention & Control Ratified
V2 September 2013 Head of Infection Prevention & Control Ratified
V3 November 2016 Headof Infection Prevention& Control
V4 24 January 2019 Specialist Infection Prevention Nurse Ratifiedat CQSCMeeting
V5 May2022 Specialist Infection Prevention Nurse New occupational health details added
V6 May2025 Head of Infection Prevention & Control Healthcareact updatedin2022
1. Introduction
A sharp is any item that is capable of penetrating the skin as well as bites and scratches. Sharps can potentially be contaminated with blood borne viruses and other micro-organisms or medicines which have the potential to cause harm. These injuries should be prevented where possible.
Provide has a Service Level Agreement (SLA) with Medigold, Occupational Health Services, for all Healthcare workers to access Occupational Services. In the event of an inoculation or contamination injury, employees can contact the Medigold occupational health duty manager through the customer services team on 0114 250 5368 email mailto:medigoldcs8@medigold-health.com and should follow the advice given within the ‘Management of Exposure to Blood Borne Viruses policy’ (IPPOL14)
2. Purpose
This policy sets out Provides approach for the safe use and disposal of sharps. This policy should be read in conjunction with the Healthcare Waste Policy, Management of Exposure to Blood Borne Viruses policy and the Health and Safety Policy.
The policy aims to ensure that:
• all sharps are used and disposed of safely
• all staff are aware of the action to take in the event of a needle stick or sharps injury
• compliance with the Health & Social Care Act (2008, 2015): criteria (1, 6, 9 &10) and the Health and Safety Regulations (2013): Sharp Instruments in Healthcare
3. Definitions
A sharp is defined as anything which may puncture skin including:
• IV Cannulae – all types
• Infusion administration sets (sharp point for puncturing containers)
• Hollow bore hypodermic needles
• Lancets
• Scalpel blades
• Scissors and razor blades
• Glass – all sources
• Sharp spicules of bone (in surgery/trauma/post-mortem)
• Teeth and nails – resulting in bites and scratches
4. Duties
Group Chief Executive
Overall responsibility for ensuring infection prevention and control is a core part of Provide Quality & Safety and Patient Safety Strategy.
Board
Collective responsibility for ensuring that appropriate and effective policies are in place to minimise the risks of health care associated infections.
Director of Infection Prevention & Control
Responsible for overseeing the development and implementation of infection prevention and control policies.
Head of Infection Prevention
Responsible for:
• ensuring this policy is reviewed and amended at the review date, or prior to this following new research
• a liaison with Health and Safety and Occupational Health on any issue relevant to safe practice
• leading on the procurement of Safety Devices
• monitoring the number of reported incidents relating to sharps injuries reported via DATIX.
• reporting incidents relating to sharps injuries to the Quality & Safety Committee.
• training staff in the safe disposal of all waste categories including sharps.
Head of Quality & Safety
Responsible for:
• when required, ensuring all Incidents are reported in compliance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR, 2013)
• investigating all non-conformance incidents/accidents resulting from waste and sharps disposal
Assistant Directors and Divisional leads
Responsible for ensuring:
• all staff have read this policy and that systems are in place to ensure compliance following assessment and management of the risks associated with the use of sharps within their particular area to minimise any identified risks
• staff have access to safety devices (needle-free) and where this is not possible, that clear risk assessments are in place and these are reviewed annually.
Director of Estates and Facilities (Inc. Health & Safety)
Responsible for:
• acting on behalf of Provide for managing external waste contractors
• ensuring that all waste, including sharps waste, is disposed of in accordance with waste legislation and the Safe Management of Healthcare Waste (2013)
• ensuring a register of all waste is kept appropriately by waste subcontractors
• providing a report of waste disposal matters to the Infection Prevention Committee as part of the Estates and Facilities report
• ensuring that all waste management contracts/ contractors, meet compliance standards within the Duty of Care Regulations and the Carriage of Dangerous Goods Regulations
Facilities and Estates Managers/Clinic Managers
Responsible for:
• ensuring the safe collection of sharps bins
• reporting all incidents of non-conformance matters relating to waste, including sharps to the Head of Estates and Facilities to investigate
Health &Safety, Resilience & Security Manager
Responsible for ensuring that pro-active arrangements are in place for the monitoring and implementation of the Healthcare Waste Policy and safe disposal of sharps.
All Healthcare Staff
It is the responsibility of staff:
• to ensure compliance with all aspects of this policy in order to protect themselves and others from sharps injury.
• to read this policy and to comply with safe systems of work and to inform their manager where their current system is unsuitable or hazardous.
• to follow the Management of Exposure to Blood Borne Viruses Policy in the case of an incident
• to inform their Line Manager and complete an Incident Form (Datix Form) as soon as possible following the incident/accident. Employers must notify their employer of a sharps accident as soon as practicable after the event (Regulation 8)
• to use and dispose of sharps in a safe manner and observe safe working practices.
• to always dispose of their own sharps and never leave sharps for others to clear away
Occupational Health Department and / or Accident & Emergency Department
• They will ensure staff who sustain an injury will be treated in line with the Management of exposure to Blood Borne Viruses Policy and in line with current national guidance
• They will liaise with service managers to ensure any required testing takes place in line with national guidance
5. Consultation and Communication
Infection Prevention Group and the Quality and Safety Committee.
6. Monitoring
This policy will be implemented via Provides MyCompliance and will be monitored by the Quality & Safety Committee.
The nominated Infection Prevention Link Practitioner working within each Service will audit the policy monthly using the ‘Essential Steps to Safe Clean Care’ Audit tool (DH 2006) Observational audit tool/hand hygiene/infection control /practice element 4 (Please refer to Essential Steps – Observational Hand Hygiene Audit Tool on the staff intranet).
This is reported as part of the quarterly Director of Infection Prevention and Control Report to the Quality and Safety Committee
7. Legislation
• Health and Safety at Work etc. Act 1974
• Control of Substances Hazardous to Health Regulations (COSHH) (2002 and updates)
• Management of Health and Safety at Work Regulations (1999 and updates)
• The Provision and Use of Work Equipment Regulations (1998 and updates)
• Reporting of Diseases Injuries and Dangerous Occurrences Regulations 2013 (RIDDOR)
• The Personal Protective Equipment Regulations (1992 and updates)
• The Health and Social Care Act (2008, 2015): Code of Practice on the prevention and control of infections and related guidance
• The Health and Safety (Sharp Instruments in Healthcare) Regulations (2013)
8. Immunisation
All healthcare workers including students and trainees who use sharps or who handle sharps containers or waste should be immunised against hepatitis B on commencement of employment if not already immunised.
9. Safe management of
sharps
and working practices
The use of sharps should be avoided where possible. When their use is essential, particular care is required in handling and during disposal. If possible, sharps with safety features should be used where local risk assessment has deemed them appropriate; safety devices are designed to minimize the risk of operator injury during use as well as preventing ‘downstream’ injuries that occur after disposal, and which often involve the housekeeping/portering staff responsible for the collection of sharps boxes and other healthcare waste EPIC 3 (2013).
Safe Handling of Sharps
• Avoid the use of sharps wherever possible
• Where possible always use a safety /needle-free device
• Do not re-sheath used needles
• Do not bend or disassemble sharps after use.
• Syringe/cartridges and needles should be disposed of intact.
• Keep handling to a minimum. Never pass sharps from hand to hand.
• Discard immediately after use into a sharps container.
• Used sharps must never be left for anyone else to dispose of. This is the users’ responsibility
• Never remove scalpel blades by hand, use forceps or a scalpel blade removing unit
• Discard cannula and intravenous lines immediately after use never cut into pieces
• Always get help when using sharps with a confused or agitated patient.
• Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel (i.e. vacutainers, retractable lancets)
Sharps Containers/differing designs
• Sharps must only be disposed of in designated sharps bins, that meet the requirements of British Standard: BS 7320 (1990) UN3291
• Ensure sharps boxes are fully assembled and labelled with the date commenced in use and date of final closure
• Ensure labels are signed by the individual responsible for assembling and locking the box
• Ensure containers and lids which require assembly prior to use are fully attached at all points before use
• Do not fill the sharps container above the manufacturers marked black line (approximately 2/3rds)
• Sharps bins should ideally be wall-mounted in a bracket between waist and shoulder height to facilitate view of aperture when disposing of sharps
• Never place sharps binson thefloor, on top of a high surface, or where children or confused adults can tamper with them
• Containers must be free from protruding sharps – do NOT dispose of a sharp if it is evident the container is full to the black line.
• If a sharps container is deemed to be full to the black line DO NOT IGNORE IT – remove from use and replace or report it immediately for replacement.
• Staff must not attempt to retrieve items discarded in sharps boxes.
• Use an appropriately sized sharps box dependant on the amount of waste produced that will last for approximately 3 months (this is a H&S requirement).
• Attention must be paid to the provision of appropriate numbers of sharps boxes in use and spare boxes must be easily available to reduce potential overfilling.
• Ensure a spare container is available when on home visits.
• Ensure the lid of the sharps box is closed when not in use and kept in a locked room.
• Sharps bins should be available at the point of use of the sharp – if necessary, use a correctly designed sharps tray to carry the container to the patient
• Sharps trays with integrated trays are available for use as part of ANTT.
• After sealing and labelling, sharps containers ready for disposal must be stored safely in a designated waste storage area away from public access
• Always carry used sharps boxes by the handle
• Never place a used sharps container in an orange clinical waste bag for disposal
• Place damaged sharps boxes into a larger sized sharps box and label
• Containers contaminated with blood should be considered for replacement as soon as practical.
Sharps Practice within a Patient’s Home
• Always take a sharps container into the home when sharps are to be used.
• If sharps container is to be left at a patient’s home for on-going treatment, ensure that the container is safely stored out of access of children or confused adults
• Sharps must never be placed in non-approved sharps containers
• Sharps must never be placed in the domestic refuse system
Pen Injectable Devices
These devices are intended for administration of injectable medications e.g. insulin. For safe use refer to MMSOP51. Where device is used a ‘needle-clipper’ is advised to reduce the risk of sharps injury. They are single–patient use. The BD Safe-Clip™ device enables the safe and easy removal of insulin syringe and pen needles, retaining them within the clipper. Remove needle from device using the BD Safe-Clip™ needle clipping and storage device and dispose in sharps container. See MMSOP51.
10.Safety Devices
Provide has a Duty of Care to provide safety devices where practicable. Staff must use safety devices/ needle-free devices if these are provided and must be trained in their use prior to implementation.
If a safety device is not provided, then the clinic/team/dept. must have a clear risk assessment in place and all staff must be aware of this. This should sit on the local risk register and be reviewed annually by the manager. The employer must identify the risk and have taken steps to avoid the unnecessary use of sharps (Regulation 5(1) (a)).
Safety devices incorporate a built-in safety feature in their design, which is intended to reduce the risk of sharps injury. An integrated safety feature is part of the basic design of safety-engineered device and cannot be removed (These devices either retract, have a sheath or blunt immediately after use).
A passive safety feature is one that does not require the user to activate it, and remains effective before, during and after use.
Many sharps injuries can be avoided by adherence to the principles of safe practice. It is possible to reduce the risk of these happening by the use of safety devices.
All new devices must be approved by theMedical Devices Group. Please refer to policy CPOL17.
11.Training
Training in sharps management will be provided at induction and as part of mandatory training.
12.References
• National Institute for Health and Clinical Excellence (2012) Infection Control: prevention of healthcare associated infection in primary and community care. London: NICE
• Safe Management of Health Care Waste (2013)
• RCN (2013) Guidance to support the implementation of The Health and Safety (Sharps Instruments in Healthcare Regulations (2013)
• Health and Social Care Act (2008, 2015, 2022)
• Health and Safety: Sharp Instruments in Healthcare Regulations (2013)
• Control of Substances Hazardous to Health Regulations (COSHH) 1999
• Loveday,H., Wilson, J., Pratt R., et al (2014) Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital infection, 86, pp. S1-70
EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’
Name of project/policy/strategy (hereafter referred to as “initiative”):
Management and Safety of Sharps Policy
Provide a brief summary (bullet points) of the aims of the initiative and main activities:
The aim of this policy is to ensure that all sharps are used and disposed of safely and that all staff are aware of the action to take in the event of a needle stick sharps injury.
Project/Policy Manager: Head of Infection Prevention and Control Date: 28.05.2025
This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.
Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.
Neutral
Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?
Neutral
Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.
Neutral
Guidelines: Things to consider
Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.
The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.
Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.
Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.
Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?
It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.
It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.
EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:
(To be used where the ‘screening phase has identified a substantial problem/concern)
This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.
Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?
N/A
Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?
N/A
Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?
N/A
Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.
N/A
Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?
N/A
Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.
N/A
Guidelines: Things to consider
An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.
It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.
The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.
If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.
Further information:
Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age
© MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’