SHARPS, NEEDLE STICK and BODILY FLUID EXPOSURE POLICY
Classification: Non-Academic
Responsible: Medical Lab Assistant Instructors, Manager of Operations School of Health, Health and Safety Committee Members, First Responders
Executive Sponsor: Vice President, Product and Operations
Approval Authority: Robertson College Leadership Team
Date First Approved: July 31, 2023
Date Last Reviewed: TBD
Scheduled Review Date: July 31, 2025 or as needed
A. PURPOSE
The purpose of this policy is to ensure that appropriate procedures and reporting requirements are followed given the discovery of a sharp, a needle stick injury or a blood and body fluid exposure at Robertson’s physical campus locations.
B. SCOPE
This policy applies to Robertson instructors, students, operations team members and Health and Safety Committee Members at all three of Robertson’s physical campus locations.
The needle stick portion of this policy is applicable to individuals associated with the Medical Laboratory Assistant program at Robertson’s Winnipeg campus location.
C. DEFINITIONS
TERM DEFINITION
Blood and Body Fluid Exposure
An incident whereby an individual is exposed to potentially infectious blood or bodily fluids via a permucosal exposure or contact with mucous membranes
Needle-Stick Injury
An injury whereby a wound is caused by needles that accidentally puncture the skin.
Personal Protective Equipment (PPE)
Gloves, gowns, masks and eye protection or face shields.
Sharps Objects that could cause a puncture or abrasion such as needles, broken glass or syringes.
Robertson Community
The Robertson Community includes all individuals who work, learn, and participate in activities at the college and includes:
- full, part-time, and microcredential students -
Operations team members
- Instructional team members
- administration team members
- contracted service providers
- volunteers
- visitors
- alumni
Health and Safety Committee Designated Robertson team members who serve on the Health and Safety Committee representing each province (AB and MB) who are responsible for identifying and implementing health and safety initiatives at the college to ensure a safe learning and working environment for the Robertson Community.
First Responder A designated Robertson team member who is trained in CPR and First Aid who is responsible for aiding in the case of an on campus emergency.
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Impacted Individual An individual impacted by a needle prick injury or blood and bodily fluid exposure.
D. POLICY Guidelines
1. Robertson recognizes its legal and ethical obligation to provide a safe working and learning environment to limit the risk of injury from exposure to sharps and bodily fluids.
2. Robertson understands that specific identification, risk assessment, management, control and reporting is required to ensure the safety of the Robertson Community.
3. Robertson recognizes that sharps may be contaminated with various types of harmful microorganisms which can be found in blood, feces or body fluids.
4. Robertson recognizes that blood and bodily fluid exposures present risk to the Impacted Individual and must be addressed through proper protocol.
5. All members of Robertson’s Community are responsible for following the procedure set out in Section E and Appendix A, B and C of this policy to ensure the correct handling, disposal and reporting related to sharps, needle stick injuries, and exposure to blood or body fluids is adhered to.
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6. Robertson adheres to the procedure described in Section E should a student or instructor incur a needle stick incident while conducting simulation labs in Robertson’s Medical Lab Assistant program at Robertson’s Winnipeg campus location.
7. Robertson is responsible for ensuring that each campus location has at least one sharp box for sharps disposal and educating campus team members about the purpose and usage of the sharps box.
8. Only trained personnel shall handle sharps, needle stick injuries and bodily fluid exposure incidents.
9. Robertson’s Laboratory Safety Guide outlines the detailed actions that are to be taken should an incident occur on campus whereby a Robertson Community Member is injured or at risk.
10. In the event of a needle prick injury or exposure to bodily fluid, a risk analysis may be completed by a medical professional to determine next steps depending on severity.
11. Robertson’s Health and Safety Committee is responsible for ensuring education and training related to sharps handling and disposal and blood and body fluid exposure at all three physical campus locations.
12. Needle Stick of bodily fluid exposures which occur at a Share Health site will follow the procedure outlined in Shared Health’s Policy: HSC - Blood and Body Fluid – Post Exposure Management (see Supporting Documentation Below).
E. PROCEDURES
Handling and Disposal of Discarded Sharps
Action
Should a discarded sharp be discovered inside or around the Robertson campus, the individual who discovered the sharp shall immediately notify Roberston reception. The individual must await the arrival of the Campus Manager or Delegate and advise others nearby to avoid the sharp.
The Campus Manager or Delegate will locate the area where the sharp was
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Responsibility
Member of Robertson Community who discovered the sharp Robertson Receptionist
Campus Manager or Delegate
Campus Manager or Delegate
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discovered, use appropriate PPE and place the sharp in the assigned disposal container which is located in the three campus locations while ensuring compliance to Appendix A: Handling and Disposal of sharps.
The Campus Manager or Delegate is responsible for arranging for appropriate disposal by ensuring proper sealing, tagging and record management of sharps for disposal as per the monthly pick up schedule. The Campus Manager or Delegate must also ensure an empty replacement container is provided immediately upon the pick up of the used sharps container.
Needle Stick
In the event of a needle stick injury, the instructor assists the impacted individual to bandage the injury ensuring that blood does not contaminate lab surfaces by following the procedure in Appendix B:
An individual impacted by a needle stick injury should proceed as soon as possible to an emergency room, urgent care facility or walk-in clinic. A risk analysis must be completed by a medical professional to determine next steps.
The instructor may contact reception to notify the First Responder for additional assistance should it be required.
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Campus Manager or Delegate Instructor Instructor First ResponderThe Instructor or First Responder must complete the incident report form as per Robertson Incident Report Policy.
The School Manager must follow up with the instructor, student and First Responder as necessary after receiving the Incident Reporting form to ensure proper documentation and reporting.
The instructor or First Responder must complete the incident report form as per Robertson Incident Report Policy.
Blood or Body Fluid Exposure
Action
In the event of a blood or body fluid exposure, the instructor must contact reception who will immediately notify the First Responder on site who is trained in CPR and First Aid as per the Health and Safety First response emergency document posted on the Health and Safety bulletin board, and as per the Health and Safety Guide.
The First Responder follows the procedure in Appendix B to assist the Impacted Individual.
An individual impacted by a bodily fluid exposure should proceed as soon as possible to an emergency room, urgent care facility or walk-in clinic. A risk analysis must be completed by a medical professional to determine next steps.
The First Responder will assist the
Instructor or First Responder
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School Manager
Instructor or First Responder
Responsibility
Instructor or Observer of Incident
Receptionist
First Responder
First Responder
Impacted Individual
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affected individual with where to go to receive this emergency care.
The instructor or First Responder must complete the incident report form as per Robertson Incident Report Policy.
The School Manager follows up with the instructor, student and First Responder as necessary after receiving the Incident Reporting form to ensure proper documentation and reporting. Update Salesforce as required.
F. RELATED LEGISLATION
N/A
E. SUPPORTING DOCUMENTATION
Instructor or First Responder
School Manager
Appendix A: Handling and Disposing of Sharps (Detailed) Procedure
Appendix B: Needle Stick (Detailed) Procedure
Appendix C: Blood or Body Fluid Exposure (Detailed) Procedure
Exposure to Human Blood (Attached to Policy as Separate Document)
Shared Health Policy: HSC - Blood and Body Fluid – Post Exposure Management (Applicable to exposures which occur during practicum at Shared Health sites)
HR Downloads: Needle Stick and Sharps Training Module
E. RELATED POLICIES
Incident Reporting Policy
F. RELATED MATERIALS
Incident Reporting Form
Emergency Contact List
Emergency First Response Plan
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First Approved: July 31, 2023
Review Approved by: Robertson Leadership Team
Signatures:
Terena Caryk
VP, Product and Operations
Belinda Loschiavo
VP, Global MB
Jason Locke
VP, Business Development
Appendix A: Handling and Disposal of Sharps
1. All sharps are to be treated as potentially contaminated; extreme caution is to be used when handling and disposing of sharps so as to avoid blood or body fluid exposure.
2. Do not try to recap, bend or break off the needle.
3. Sharps are not to be transported to a container. The sharps container is to be taken to the area requiring the disposal or clean up.
4. Only trained personnel shall handle sharps. Before doing so, ensure you are wearing appropriate PPE such as disposable waterproof gloves to handle tongs and protective eyewear when the splashing of fluids presents a risk.
5. Place the disposable container close to the sharps; to do so:
- ensure the needle is pointing downwards
- pick up the needle using rubber gloves tweezers or tongs
- keep the sharp end away from you.
- place the needle in the container, sharp end down, place the lid on the container.
6. Remove gloves and wash hands with soap and water.
7. Inform Reception to contact Janitorial Services to conduct a thorough cleaning of the contaminated area as required.
8. Inform the Facilities Manager of the incident; complete the Incident Report within 24 hours.
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Appendix B: Needle Stick (Detailed) Procedure
1. Have the individual wash the injured area with soap and water.
2. Ensure the individual does not attempt to squeeze the wound.
3. Do not use alcohol, hydrogen peroxide, bleach or other antiseptics on the wound.
4. Communicate to the individual that the wound should bleed freely (if bleeding is present) at first; then have them cover it with a bandage to prevent further exposure. Obtain the appropriate size of bandage from the first aid kit in the classroom.
5. Ensure the wound has been properly bandaged.
6. Anyone who has had a needle stick injury should proceed as soon as possible to an emergency room, urgent care facility or walk-in clinic. A risk analysis must be completed by a medical professional to determine next steps.
7. Inform Reception to contact Janitorial Services to conduct a thorough cleaning of the contaminated area as required.
8. Inform the School Manager of the incident; complete the Incident Report within 24 hours.
Appendix C: Blood or Body Fluid Exposure (Detailed) Procedure
1. In the event of a blood or body fluid exposure, have the individual flush the exposed mucous membranes (eyes/nose and mouth) with water or normal saline. (*Normal saline solution can be found in the first aid kit in the classroom).
2. Anyone who has had a needle stick injury should proceed as soon as possible to an emergency room, urgent care facility or walk-in clinic. A risk analysis must be completed by a medical professional to determine next steps.
3. Inform Reception to contact Janitorial Services to conduct a thorough cleaning of the contaminated area as required.
4. Inform the School Manager of the incident; complete the Incident Report within 24 hours.