Why zero isn't the only sharps safety goal

Underreporting can hide sharps problems

No more needlesticks. That sounds like a laudable goal that could prevent health care workers from being exposed to deadly diseases. But, in tandem, outpatient surgery managers need to maintain another important message that could actually cause their numbers to rise: Report all needlesticks.

In a brochure that targets first responders, the National Institute for Occupational Safety and Health (NIOSH) is urging employers to encourage reporting of bloodborne pathogen exposures. Underreporting not only means a failure to follow up on an employee exposure, but it also hampers efforts to improve sharps safety programs, says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.

"Studies that have been done of underreporting have ranged from 30% to 80%, depending on the occupational group," she says. Physicians, and especially surgeons, are the least likely to report, Perry says.

Employers need to be proactive and remove some of the barriers to sharps injury reporting. "Make reporting as easy as possible," and make it easy to report 24-7, says Winnie Boal, MPH, epidemiologist with NIOSH's Division of Surveillance, Health Evaluations, and Field Studies.

Sure, employees hear the information about reporting bloodborne pathogen exposures during annual training. But it takes effort to keep the message fresh and vital so employees don't tune it out, just as frequent air travelers ignore the safety message at the start of every flight. "I think the most important message is every worker should report every injury," says Perry. "Those are the building blocks for improving safety in the [health care] environment. That data is important for us."

Tell employees, "'We need to know from you what safety devices are working and which aren't. You can help us create a program that works by reporting your injuries,'" she adds.

Reporting needlesticks is an essential part of a safety climate, a work environment that places a premium on employee and patient safety, says Robyn Gershon, DrPH, professor in the Mailman School of Public Health at Columbia University in New York City. "Workers who say, 'I didn't think the patient was at risk,' are kidding themselves, or they're in some kind of denial," she says. "I think every stick should be taken seriously."

There are numerous reasons why health care workers fail to report needlesticks. Among those cited by NIOSH:

  • They do not think they will get an infection from the exposure.
  • They are embarrassed by the exposure incident.
  • They think it takes too much time away from work to report.
  • They think reporting may result in a negative performance evaluation or they fear losing their job.
  • They are not sure whether certain incidents should be considered exposures.

A survey of paramedics indicated that about half (51%) failed to report blood exposures and about a quarter (28%) failed to report needlesticks. The main reason for underreporting was their belief that the exposure wasn't a "significant risk." They also were less likely to report if the exposure was "under [their] control."1

Efforts to encourage reporting should target the common perceptions about risk and fears of reprisal. Here are some suggestions from NIOSH and sharps safety experts about what employers should do to improve reporting of bloodborne pathogen exposures:

  • Establish a policy that all potential exposures must be reported. Employees should not decide which needlesticks pose a risk and which do not. In fact, Gershon says, even "clean" sticks, sticks with uncontaminated needles, should be reported. After all, the reporting of needlesticks is essential information when employee health professionals evaluate the effectiveness of sharps safety devices. (The U.S. Occupational Safety and Health Administration requires reporting only of sharps injuries that involve potentially contaminated material.)
  • Train supervisors, not just employees. If your policy is not communicated effectively to supervisors, they may make ad hoc decisions, says Gershon. Employees might think that reporting will have a negative effect on their performance evaluation, especially if they have had a prior needlestick. Repeat needlesticks might indicate a faulty device, poor work practices, or even a personal problem (such as an employee coping with divorce or family illness). An astute supervisor may determine whether the employee needs additional training or could benefit from referral to an employee assistance program, says Gershon.
  • Identify barriers to reporting. Reporting should occur as soon as possible after the injury so follow-up and any necessary treatment can begin, says Boal. The biggest barrier: Employees are worried about who will be caring for their patient. Employers should provide a mechanism for backup support and rapid HIV testing, making "the reporting and evaluation process as short as possible and efficient as possible so employers aren't so reluctant to leave their worksites," says Boal. Your process also should take into account non-English-speaking employees, who face a language barrier and also may fear reprisal for reporting, notes Perry.
  • Provide regular feedback to staff on needlestick events. Successful programs track needlesticks and share that information by department on a regular basis, says Perry. For them, sharps safety is an ongoing effort. NIOSH also encourages employers to use marketing techniques to emphasize reporting, such as posters and handout cards with the reporting protocol.
  • Show employees that reporting of needlesticks has an impact. If you change a device because of a high number of needlesticks, let employees know that you responded to their reports of injury. Be alert for changes you can make in the work environment as well.

The bottom line from needle safety experts: You don't want to have "zero needlesticks" simply because your employees aren't reporting them. Reporting may make your injury rate go up, temporarily, but then you can take effective steps to create a safety workplace.


  1. Boal WL, Leiss JK, Sousa S, et al. The national study to prevent blood exposure in paramedics: Exposure reporting. Am J Ind Med 2008; 51:213-222.