Policy Manual sample

MDT Home Health Care Agency, Inc. 228 SHARPS INJURY LOG Please complete a Log for each employee exposure incident involving a sharp. Employee Name: Department: 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  MD  Patient Home  Nurse: RN LPN/LVN NA  Service/Utility Area  Tech: RT PT  Other:  Phlebotomist/Lab tech  Other:  Housekeeper/Janitor  Other:  Student, type:  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: