Needlestick and sharps object injuries (NSOIs) are preventable events in healthcare facilities, yet most NSOIs occur in the operating room (OR). The Occupational Safety and Health Administration (OSHA) defines NSOIs as follows: “Sharps are objects that can penetrate a worker’s skin, such as suture needles, hollow-bore needles, scalpels, broken glass (including glass ampules), capillary tubes, and the exposed ends of wire.”
Legislation to address workplace NSOIs began in 1991, with the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030). The Bloodborne Pathogens Standard required reporting of the type and brand of the device involved, the department where the NSOI occurred, and a description of the event. In 2000, the Needlestick Safety and Prevention Act (Public Law 106-430) required OSHA to revise the Bloodborne Pathogens Standard to strengthen worker protection against injuries from sharp devices. The revision strengthened requirements for the use of safer medical devices (e.g., sharps with engineered sharps injury protection), mandated the recording of events through a sharps injury log, and required proper disposal of sharps in US healthcare facilities. OSHA publishes Letters of Interpretation to provide guidance and keep the Bloodborne Pathogens Standard aligned with new information. According to OSHA, each letter “constitutes OSHA's interpretation of the requirements discussed.” Hospitals from across the country voluntarily submitted data about NSOI events to the Exposure Prevention Information Network (commonly known as EPINet).
Up to 69% of healthcare workers experience an NSOI, with a higher incidence occurring at teaching hospitals and hospitals with more than 300 beds. The OR is the most common location for NSOIs to occur, with an annual prevalence of 5% of healthcare workers reporting an NSOI in the OR. Surgeons and nurses are at the highest risk for injury while using the device or passing and disposing of sharps. The rate of NSOI initially decreased after legislation; more recent data show sharps-related injuries are on the rise.
Injury data using the number of sharps devices purchased as the denominator (rather than the number of beds or staff) provide a more accurate and comparable measure of sharps‑injury risk. This approach aligns the injury rate with actual exposure opportunities and enables more meaningful risk assessments, evaluation of intervention efficacy, and benchmarking across US hospitals. For example, for every 100,000 syringes and needles purchased, there were 2.7 sharps injuries. For every 100,000 scalpels purchased, there were 12.6 sharps injuries, and for every 100,000 suture needles purchased, there were 31.9 sharps injuries. These data illustrate how risk varies substantially by device type and highlight the value of using device purchase volumes to interpret injury rates.
Combining injury data and purchasing data provides useful, practical insights beyond those offered by historical injury reporting. This data approach should be used in conjunction with historical sharps injury data.
The ACS supports work practices designed to eliminate, protect against, or standardize the use of sharps instruments in the OR. The ACS also recommends the use of structured evaluations and user-based criteria, including performance standards, task analysis, simulation, and training programs for devices intended to reduce sharps injuries in the OR. A team-based approach is critical to reducing the risk of bloodborne infections from sharps injuries in the OR. Hospitals and healthcare facilities should make sharps injury reduction techniques and processes available to surgeons and OR personnel.
Hierarchy of Controls
The Hierarchy of Controls (HoC) emerged in the mid-20th century as safety experts moved away from approaches that relied primarily on changing worker behavior, which had limited effectiveness. In contrast, the HoC framework prioritizes system-level interventions to create safer work environments and reduce the risk of injury.
The HoC describes five levels: elimination, substitution, engineering controls, administrative controls, and personal protective equipment (PPE). The top levels are the most effective at mitigating risk, and the bottom levels are the least effective. Therefore, PPE is best used as a supplement to higher-level controls and should not be relied on as the sole means of protection when more effective options are feasible.
ACS Recommends: The use of HoC to identify a preferred order of action to control exposure to hazardous workplace events best, and as a systematic implementation tool to achieve these changes.
Level 1–Elimination
Elimination is the most effective way of preventing sharps injuries. Examples include replacing intravenous (IV) and intramuscular (IM) injections with oral and/or transdermal preparations.
ACS Recommends: Eliminating the unnecessary use of sharps, for example, by replacing IV and IM injections with oral and/or transdermal preparations as soon as the clinical conditions allow.
Level 2–Substitution
When elimination is not feasible, substitution is a preferred strategy for reducing sharps injuries. This may include replacing higher-risk devices with safer alternatives, such as needleless IV systems or alternative wound-closure methods.
Suture Needle Types
Suture needle injuries pose the greatest risk of sharps injuries to surgeons and scrub personnel. Suture needles are most commonly responsible for NSOI, accounting for 23.6% of these injuries in 2024. Suture needles are the most likely sharp to produce an injury in the OR. For every 100,000 suture needles purchased, 31.9 will be involved in an injury. Skin staples, adhesive dressings, and glues are alternative non-suture methods of skin closure.
Blunt-Tip Suture Needle
The effectiveness of using blunt-tip suture needles instead of sharp-tip suture needles to reduce injury is supported by a Cochrane review. The substitution of sharp-tip needles with blunt-tip needles when closing fascia is recommended in order to prevent skin injury and exposure to blood and bodily fluids.
The use of blunt-tip suture needles reduced the risk of glove perforation by 54% and the risk of self-injury by 69% following the adoption of these needles. Although blunt-tip needles may be less convenient for surgeons, their ability to reduce the risk of potentially fatal bloodborne infections in healthcare personnel strongly supports their use when clinically appropriate.
ACS Recommends: The adoption of blunt-tip suture needles for the closure of fascia and muscle to reduce needlestick injuries for surgeons and OR personnel when clinically appropriate.
Level 3–Engineering Controls
Engineering controls are the next best way of preventing sharps injuries, and the best way of preventing scalpel injuries, specifically. Engineered sharps injury prevention (ESIP) mechanical devices may provide varying degrees of mechanical protection from sharps injuries.
Engineering control devices can be categorized into two groups. Passive (or automatic) safety devices activate automatically and generally offer greater protection than active (manual) devices, which require user activation and are therefore more prone to error.
Previous studies have shown that activation of active safety devices was as low as 19% (i.e., the safety feature was not activated in 81% of cases). Other studies have demonstrated that active safety‑engineered devices are up to 70 times more likely to be involved in a sharps injury than passive safety devices.
Examples of passive safety devices include spring-loaded safety syringes and single-handed scalpel blade removers. Examples of active safety devices include safety syringes using a manually operated sliding shield or cap and safety scalpels.
In 2001, the Massachusetts Department of Public Health established the Massachusetts Sharps Injury Surveillance System (MSISS) (MGL/Chapter 111 section 53D). The MSISS reported that slightly more injuries occurred in 2022 when using ESIP devices than sharps without safety features.
Violations of the Needlestick Safety and Prevention Act can result in fines for failure to use ESIP mechanical devices, improper sharps containers, or other more serious violations.
Although safety-engineered devices are more expensive than their standard counterparts, the benefits of reducing the risk of serious and potentially fatal blood-borne infections for healthcare personnel support their use when clinically appropriate.
ACS Recommends:
- Passive (or automatic) safety devices should be used in preference to active (or manual) safety devices to reduce the risk of human error and provide superior safety to the surgical team.
- Engineering controls, such as single-handed scalpel blade removers, should be used instead of fingers, needle holders, forceps, and two-handed devices to remove scalpel blades when these safety devices are available.
- When a surgeon decides to use a reusable metal scalpel handle for patient safety, a single-handed scalpel blade remover should be used, when available, to ensure protection of the surgical team and downstream workers.
- Immediate containment of the removed sharp is recommended to protect downstream workers from sharps injuries.
Disposal
The immediate and appropriate disposal of sharps has been championed in hospitals. However, studies show that a 10% NSOI rate occurs during or after disposal. In 2022, 2% of injuries occurred during the transfer of sharps to the safety container, and 4% occurred during the disposal of the sharps container. Improper disposal accounted for more injuries, and care must be taken to prevent injuries from sharps protruding from or piercing through disposal containers. Safety devices should immediately contain the removed sharp.
ACS Recommends: The use of sharps containers with adequate safety measures by staff when disposing of sharps.
Level 4–Administrative Controls
Administrative controls ensure that staff change the way they work and that the implementation of control measures is successful. Examples include developing an exposure control plan, sharps injury reporting and investigation processes, and safety training programs. These controls also include banning recapping of needles and ensuring that neutral zone/hands-free techniques (HFTs) are introduced.
Passing sharps is associated with up to 11% of perioperative injuries. The HFT requires the surgical team designate a sharps neutral zone (e.g., a towel, container, Mayo stand, magnetic pad) for the pickup and release of surgical sharps. With this approach, there is no direct handing of instruments from the scrub person to the surgeon and back. A 1995 study found that using a HFT to transfer sharps reduced NSOIs in the OR by 59% over 6 months when blood loss was minimal. Its effectiveness decreased when blood loss exceeded 100 mL per case. However, compliance with HFT remains limited.
Closed-loop communication includes the surgeon verbalizing the transfer of a sharp to the neutral zone and the scrub technician communicating the retrieval and securement of the sharp. Sharps should be placed so the scrub can grasp the non-sharp end, the sharp is protected, and only one sharp is transferred at a time. OSHA and the Association of periOperative Registered Nurses support the use of a neutral zone as a method to reduce healthcare workers’ risk of sharps injury during surgery. A neutral zone is a team effort that requires communication and commitment from the surgical team.
ACS Recommends:
- An HFT or neutral zone should be used as an adjunctive safety measure to reduce sharps injuries while passing instruments during a surgical procedure.
- Half of all sharps injuries are unreported. This reality results in poor data collection and potential harm to clinicians and healthcare workers. The ACS supports mandatory reporting of all sharps injuries.
Level 5–Personal Protective Equipment
PPE is the lowest level of control and the least effective means of addressing sharps-related hazards. It should be used in conjunction with higher-level controls and not relied on as a substitute when more effective measures are feasible. Examples include safety glasses/face shields, double-gloving, and footwear designed to protect the wearer from blood and body fluids and from injury from dropped sharps.
Surgical gloves were introduced by William Stewart Halsted in 1889, as PPE for the OR team. They create a protective barrier that reduces occupational exposure to blood-borne pathogens and other infectious materials. Percutaneous exposure injuries can still occur if a glove is punctured.
Glove perforation occurs in 7.8% of all surgeries. Double-gloving reduces skin perforations and blood contamination compared to single gloving. A Cochrane review unequivocally supports the use of double-gloving and reports a 71% reduction in the risk of glove perforation. Perforations were found in 17.9% outer gloves and just 1.3% of inner gloves. The indicator glove reduced the number of perforations per glove and provided earlier recognition of perforation. Thicker gloves and hand dominance did not impact the glove perforations. A Cochrane review found that dexterity was not affected by double-gloving.
ACS Recommends:
- The adoption of the double-glove technique with an indicator glove to reduce exposure to bodily fluids resulting from glove perforations.
- The use of shoes featuring enclosed toes, nonporous materials, and slip-resistant soles, along with glasses or face shields where indicated.
Culture of Safety
The ACS endorses the increasing importance of workplace safety and believes in striving for one safe culture for all (StaffAndPatientSafety.org). The positive relationship between staff safety and patient safety is highlighted by researcher Alexandra Shaw and colleagues: “There now needs to be universal recognition that health worker safety is patient safety. One cannot exist without the other.”
