Why are 1 in 3 sticks linked to hypodermics?

Lack of reg compliance, widely used

About one out of every three needlesticks occurs with a hypodermic syringe — a device that is available with many types of safety features. As thousands of needlesticks continue to occur from hypodermic needles, hospitals need to do a better job of protecting health care workers from bloodborne pathogens, safety experts say.

In 2009, for example, 884 of 2,889 sharps injuries reported by Massachusetts hospitals involved hypodermic needles. Massachusetts hospitals are required by state law to report their sharps injuries. Almost one-third of those injuries (274, or 31%) involved devices that lacked safety features.1 A similar proportion of sharps injuries (31%) involved hypodermic needles in the 2007 EPINet surveillance data of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.

"Clearly, those are most often cases where people are not complying with both state and federal regulations to use appropriate devices," says Angela Laramie, MPH, epidemiologist with the Massachusetts Department of Public Health Occupational Health Surveillance Program.

As the Needlestick Safety and Prevention Act enters its second decade, there has been a renewed push for further progress. In a regional emphasis program, U.S. Occupational Safety and Health Administration inspectors will target bloodborne pathogen hazards at outpatient centers in Florida, Alabama, Mississippi and Georgia. (See related article on p. 76.) Under president Karen A. Daley, PhD, MPH, RN, FAAN, who acquired HIV and hepatitis C from a needlestick, the American Nurses Association relaunched its Safe Needles Save Lives campaign. In addition, Becton, Dickinson and Company of Franklin Lakes, NJ, the largest needle and syringe manufacturer in the world, has created a new web site to highlight the stories of health care workers who had mucocutaneous exposures.

Devices in kits cause 20% of injuries

Why are needlesticks with hypodermic needles so persistent? One reason for the higher numbers is mathematical: "They've always accounted for the highest proportion of injuries because they're the most commonly used device," notes Jane Perry, MA, associate director of the International Healthcare Worker Safety Center.

There also is easy availability of conventional hypodermic needles because they are used in pharmacies and for other non-patient-related tasks, she says. "[The data] shows that there's a continuing need to analyze our needlestick data and look for areas where we need to address lack of use of safety devices," she says.

Laramie evaluated sharps injuries that occurred from 2006 to 2009. One in five (20%) of all sharps injuries occurred with devices that were supplied in pre-packaged kits for procedures. There is a particular problem with kit suppliers including syringes and needles with no sharps injury prevention features, says Laramie.

Hospitals that insist on safety devices in the kits are often told they will need to purchase customized kits — at a much higher price, she says. "The custom kits should be the ones lacking sharps injury prevention features," she says.

The lack of sharps safety features in kits has been a longstanding problem, says Perry. "There appears to be a Catch-22 where the company is saying, 'We're supplying what the customer wants,' and the hospitals are saying, 'This is what the suppliers are supplying us with.' Something has to break that [cycle]," she says.

Task analysis ID's best practice

There are circumstances in which health care providers say they need to use conventional needles to perform a procedure. Yet those cases should be evaluated to see if safer options are possible, says June Fisher, MD, director of the TDICT (Training for Development of Innovative Control Technologies) Project in San Francisco. A task analysis can help OR nurses determine the best devices that provide safety as well as meet the needs of the procedure, she says.

For example, one hospital was using conventional syringes or not engaging safety syringes because the same patient would receive multiple injections of a local anesthetic. The chief resident tracked the usage and found that the anesthetic was typically applied four times. So prior to each procedure, four safety syringes were drawn with Novacaine and the safety feature was engaged after each use, Fisher says.

The cost of the additional syringes was outweighed by the reduction in risk of needlesticks, which can involve costly follow-up or post-exposure prophylaxis and unnecessary anxiety for health care workers, she says.

Searching for a better device

Not all safety features are equally effective. That finding in a French study has triggered a reevaluation of sharps injuries and the devices that cause them.

An analysis of 435 sharps injuries at 61 hospitals in France found that passive devices, such as self-blunting needles that are activated automatically during use, were involved in the fewest injuries. "Semi-automatic" devices, in which the user must apply extra pressure to activate the safety mechanism, such as some retractable syringes, were associated with the next fewest injuries. Those with a "toppling shield" that requires one-handed activation to cover the needle were more effective than sliding shields, which often require two-handed action and were the least effective, the authors said.

In 2010, Massachusetts began asking hospitals to provide information about the safety mechanisms. "Hopefully in the future we can make some statements about the mechanism [involved in injuries after use]," Laramie says.

The Bloodborne Pathogen Standard of the U.S. Occupational Safety and Health Administration requires hospitals to update their exposure control plans each year and to evaluate new technologies.

Meanwhile, there has been some continued progress in preventing sharps injuries. Although the number of sharps injuries has remained steady, the rate has declined, says Laramie. "When we looked at the rate of injuries with hypodermic needles and syringes between 2002 and 2009, and we used licensed beds as our denominator, we did see a statistically significant decline," she says.

The needlestick law places the onus on employers to purchase safety devices, with input from frontline health care workers. But manufacturers will need to work with hospitals to provide devices that are effective and easy to use, Laramie says.

"The manufacturers have the ability and the responsibility to remove as many barriers as possible in order to make it possible for the right products to get into the hands of the clinicians," she says.


1. Massachusetts Department of Public Health Occupational Health Surveillance Program. Sharps injuries among hospital workers in Massachusetts, 2009: Findings from the Massachusetts Sharps Injury Surveillance System. Boston, MA, 2011. Available at http://1.usa.gov/jjvuxn

2. Tosini W, Ciotti C, Goyer F, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infect Control Hosp Epidemiol 2010; 31:402-407.