Infection Prevention Manual

SHARPS INJURY LOG Please complete a Log for each employee exposure incident involving a sharp. Employee Name: Title: Date of Injury: Time of Injury: AM/PM Complete this form and a Supervisor Injury Report. Send employee to be seen by physician. Sharps Injury Log and Supervisor Injury Report are to be forwarded to Human Resources after employee is seen by physician. Description of the exposure incident: Job Classification Location Registered Nurse Patient Home LPN/LVN ALF/Nursing home Prof: RT PT OT ST Other: HHA/CNA Other: Housekeeper/Homemaker Other: Dietician/Nutritionist Other: Procedure Did the exposure incident occur: Draw venous blood During use of sharp Draw arterial blood Between steps of a multistep procedure Injection, through skin After use and before disposal of sharp Start IV/set up Saline Lock While putting sharp into disposal container Unknown/not applicable Sharp left in inappropriate place (table, bed, etc.) Heparin/Saline Flush Disassembling Cutting Other: Suturing Other: Body Part Check all that apply Identify sharp involved (If known) Did the device being used have engineered sharps injury protection? Finger Type: Yes No Don’t Know Hand R L Brand: Was the protective mechanism activated? Arm R L Model: Yes - Fully Yes - Partially Face/Head i.e., 18 ga needle/ABC No Torso Medical/“No stick” syringe Did the exposure incident occur: Leg R L Before During After activation Exposed Employee: If sharp had no engineered sharps injury protection, do you have an opinion that such a mechanism could have prevented the injury? Exposed Employee: Do you have an opinion that any other engineering, administrative or work practice control could have prevented the injury? Yes No Yes No Explain: Explain: Your Agency Name (PN System)