Prevention of sharp injuries

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Ellen Schmitz-Felten (Kooperationsstelle Hamburg IFE GmbH)

Introduction

Sharps and needlestick injuries are wounds caused by needles and other sharp medical instruments (e.g. scalpel, blades and scissors) that accidentally puncture or cut the skin. Sharps and needles may only cause small wounds in the skin, but the effects can be worse. Such instruments come in contact with blood and other body fluids and may carry the risk of infections. More than 20 dangerous bloodborne pathogens including HIV and hepatitis may be transmitted through accidental injuries with contaminated needles and sharps [1].

This article gives an overview about the risks associated with sharps and needlestick injuries, and about European legislation. It will focus on prevention measures, such as safe injection practices, safe medical devices, and training. In addition, it will provide information on what to do in case of an injury.


Who is at risk of sharps injuries?

Sharps and needlestick injuries remain a serious problem in the healthcare sector. Studies estimate around 1.2 million injuries annually in Europe [2]. However, a large number go unreported (estimated at between 26% - 90%) [3]. Mülder has labelled needlestick injuries as “the trivialised mass accident” [4].

Other workers at risk of sharps injuries are: social workers, cleaning/laundry personnel, park-keepers, police officers, prison officers, and workers involved with waste disposal including street cleaning and refuse collection [5][6].


In healthcare, it is not just medical professionals who are at risk from sharps injuries, but rather anyone who comes into contact with needles or medical sharps contaminated with blood or other body fluids. The majority of sharps injuries occur to nurses, because their daily routine involves using needles and sharps (see also health service). While nurses who work in acute medical situations are identified as having the highest risk, many other healthcare workers are also at risk [5], such as [7]:

  • Doctors
  • Paramedics
  • Dentists
  • Operating department assistants
  • Phlebotomists
  • Laboratory workers
  • Cleaners
  • Laundry workers.

Workers outside the healthcare sector may also be at risk because they may come across material that is contaminated with blood and bodily fluid, such as needles used by intravenous drug users [5].

Professions where workers may be at risk include:

  • Prison and probation service
  • Cleaners of public spaces
  • Police and security services
  • Customs services
  • Social service workers and youth workers
  • The funeral industry
  • The body piercing/body art industry
  • Waste disposal
  • The construction/demolition industry.

What are the most common causes of sharps injuries?

Sharps or needlestick injuries are generic terms for injuries where infectious blood or other body fluids can come into contact with wounds or mucous membranes [5] The most common injuries are needlestick punctures or cuts with medical instruments, but also include [8]:

  • Contamination of broken skin with blood
  • Swallowing a person’s blood e.g. after mouth-to-mouth resuscitation
  • Contaminated through being soaked by blood where the injured person has an open wound / blood on clothes
  • Bites (where the skin is broken).

Factors that can influence the risk of sharps injuries are equipment, design of instruments, working conditions and working practices (see also Job design and Organisational measures). According to the US Center of Disease Control and Prevention (CDC), sharps injuries often occur in a fast-paced, stressful and understaffed situation [9]. Working under such a demanding situation may result in fatigue, poor concentration, and carelessness, thus increasing the risk of sharps injuries. Studies show that long working hours and sleep deprivation among medical trainees results in fatigue, which is associated with a 3-fold increase in the risk of sharps injury [10] (see also Accidents and incidents)(Tab. 1).

Sharps injuries can also be associated with certain working practices that increase the risk of exposure to infectious body fluids, such as unsafe collection and disposal of sharps waste and re-capping of needles [11][12].


Table 1: Most common causes of sharps injuries

  • Overuse of injections and unnecessary sharps
  • Lack of supplies: disposable syringes, safer needle devices and sharps disposal containers
  • Lack of access and failure to use sharps containers immediately after injection
  • Lack of personal protective equipment, safety devices, and sharps disposal containers,
  • Inadequate or short staffing
  • Recapping of needles after use
  • Lack of engineering controls such as safer needle devices
  • Passing instruments from hand to hand in the operating suite
  • Lack of hazard awareness and lack of training
  • Unexpected patient reactions

Source: adapted from Wilburn et al. 2005 [11]

Many devices cause sharps injuries: needles, scalpels, blades, scissors, and test tubes. However, biological matter (such as bone fragments or patients’ teeth) can also cause sharp injuries [7]. Hollow-bore needles contaminated with blood account for most of the injuries among the devices. A survey carried out by the UK Health Protection Agency (HPA) reported that between 2000-2007, 68% of injuries caused by needles and other sharps were attributed to hollow-bore needles, 19% to solid needles, and 13% were stated as ‘other’ sharp tools, such as scalpels [13]. The highest risk of being infected by hollow-bore needles comes from blood collection, intravenous cannulation, and percutaneously placed syringes [14]. According to the HPA survey, over three quarters of occupational exposure to blood and other high-risk body fluids occurred in wards, operating theatres, accident and emergency units and intensive care units [13].

What can be contracted from a needlestick?

Contaminated needles and sharps can transmit more than 20 dangerous bloodborne pathogens, viruses, bacteria and protozoa, including HIV and hepatitis B (HBV) and C (HBC) [15] (see also Biological agents).

Diseases transmitted through infected blood include:

  • Viral infections, e.g. hepatitis B, C, HIV,
  • Bacterial infections, e.g. tuberculosis and diphtheria,
  • Protozoal infection, e.g. malaria (plasmodium falciparum) and toxoplasmosis,

Infections from bloodborne pathogens can result in serious illness and even death. one microlitre of blood from a used hollow bore needle can transmit enough germs for an infection [16].

After exposure to blood and body fluids due to needlestick injuries, the risk of being infected with Hepatitis B is 3-10%, for Hepatitis C it is 1-3%, and 0.3% for HIV [11]. Hepatitis C represents the most serious health risk as it is ten times more transmissible than HIV and there is currently no vaccine [17]. The risk of infection depends on a range of factors, such as the depth of wound, the type of sharp instrument, whether or not the device was previously in a vein or artery, and how infectious the patient is [7].


Legislation

All workers are protected by the framework Directive 89/391/EEC [18]. This Directive’s basic principle is risk prevention, which requires employers to carry out risk assessments, and imposes a general duty on them to ensure the health and safety of employees. The Directive is supplemented by individual Directives [19] (see also Legislation).

The European Parliament and the Council issued Directive 2000/54/EC on 18 September 2000 [20]. Its aim was to protect workers against risks to their health and safety, arising (or likely to arise) from exposure to biological agents at the workplace. This Directive sets out provisions to guarantee improved OSH where workers may be exposed to biological agents as a result of their work.

On 6 July 2006, the European Parliament adopted resolution 2006/2015 (INI) [21] to protect European healthcare workers from bloodborne infections due to needle stick injuries.

A Europe-wide framework agreement on the prevention of sharps injuries was signed on 17 July 2009 by HOSPEEM (European Hospital and Healthcare Employers' Association) and EPSU (European Public Services Union) – the European social partners in the hospital and healthcare sector [22]. The Agreement makes clear that healthcare staff are at risk of serious infections due to their daily work. More than 20 dangerous pathogens, including hepatitis B, C, and HIV, can be transmitted as a result of needlestick injuries [1].

The Council Directive 2010/32/EU [23] on prevention of sharp injuries in the hospital and healthcare sector brought into law the framework agreement negotiated by the sector’s European social partners. It applies to all workers (private and public) in the healthcare sector, as well as students, agency nurses, and healthcare staff in other workplaces, such as prisons. The key requirement of the Directive is risk assessment. The aims of the Directive are:

  • Achieving the safest possible working environment;
  • Preventing workers’ injuries caused by all medical sharps;
  • Protecting workers at risk;
  • Setting up an integrated approach, establishing policies in risk assessment, risk prevention, training, information, raising awareness and monitoring;
  • Establishing response and follow up procedures.

Member States must implement Directive 2010/32/EU [23] by May 2013.

Other individual Directives for protecting healthcare workers are Council Directive 89/655/EEC [24], which lays down the essential health and safety requirements for work equipment, and also Directive 92/85/EEC [25], which provides specific protection for pregnant workers or recent mothers. This directive states that employers must take all appropriate steps to ensure that neither the worker nor the unborn child is exposed to a health risk in the workplace (see also Expectant mothers,Gender, and Young workers).


Risk assessment

Risk assessment means identifying hazards and controlling the risks in the workplace. The EU framework Directive 89/391/EEC [18] obligates employers to ensure every aspect of workers’ health and safety, and to carry out a risk assessment (for detailed information see EU-OSHA [5]). Clause 5 of Directive 2010/32/EU [23] stipulates that "risk assessment shall include an exposure determination, understanding the importance of a well resourced and organised working environment and shall cover all situations where there is injury, blood or other potentially infectious material." And, further, that "risk assessments shall take into account technology, organisation of work, working conditions, level of qualifications, work related psycho-social factors and the influence of factors related to the working environment." (see also OSH Risk assessment methodologies and OSH management and Risk Governance).

Risk assessment - the basis for successful OSH management - is the key requirement of Directive 2010/32/EU [18]. The guiding principles that should be considered throughout the risk assessment process can be broken down into five steps [5][26]:

Step 1 – Identifying hazards and those at risk

All sharps injuries are a hazard that can lead to a risk of infection: What might cause harm? What can go wrong?

Finding the answer is possible, by:

  • Determining how many and which workers are exposed. Taking into account that there are many types of workers that might be exposed to sharps injuries (clinical staff, ancillary staff, laboratory staff).
  • Identifying the Working practices where sharps injuries occur.
  • Identifying practices with a higher injury risk.
  • Using existing data on sharps injuries to identify high-risk areas.

Step 2 – Evaluating risks and prioritising

What is the likelihood of it happening? How bad would it be if it did happen?

Risks are assessed and prioritised according to the hierarchy of control measures:

  1. Elimination of risk
  2. Isolation of the hazard: engineering control, protective devices
  3. Collective control measures – (work practice control, and administrative controls)
  4. Individual control measures – (personal control, PPE)

Step 3 - Deciding on the preventive action

How can the risk of sharps injuries be eliminated or reduced?

Identifying the appropriate measures to eliminate or control the risk, e.g.:

  1. Elimination of risk: removing sharps and needles when possible; considering whether the task is necessary, e.g. by eliminating unnecessary injections
  2. Isolation of the hazard through engineering control: use of sharps protection devices
  3. Collective control measures: a) administrative control (policies and procedures to limit hazard exposure), and b) work practice control (safe disposal of needles, no re-capping, safe sharps containers)
  4. Individual control measures: double gloving (PPE)

Step 4 – Taking action

  • Putting in place the preventive and protective measures, and specifying who does what and when.

Step 5 – Monitoring and reviewing

  • Recording findings: The findings of the risk assessment should be recorded and be part of an action plan to reduce the risk of sharps injuries. The outcomes should be shared with all workers.
  • Reviewing the assessment and updating if necessary: checking the effectiveness of control measures.

Prevention measures – elimination, prevention, and protection

Prevention measures to eliminate or reduce sharps injuries can be done in different ways. The Directive 2010/32/EU [23] lists a variety of preventive and protective measures, which must be considered when aiming to eliminate the risk of sharps injuries (see also Risk management for dangerous substances). These measures include:

  • Eliminating the unnecessary use of sharps
  • Providing medical devices
  • Incorporating safety-engineered protection mechanisms
  • Implementing safe systems of work
  • Implementing safe procedures for using and disposing medical sharps
  • Banning recapping
  • Using personal protective equipment
  • Vaccination
  • Information and training

Directive 2010/32/EU [23] states that employers must comply with the hierarchy of controls as set out in European Directives 89/391 [18] and 2000/54/EC [20]. The hierarchy of controls, reflecting the efficacy of the measures, indicates that the first priority and most effective level is the elimination or substitution of needles and other sharps, where possible, i.e. eliminate unnecessary injections, introduce needleless intravenous (IV) systems (see also Hierarchy of prevention and control measures).

The next level is to isolate the hazard through the use of an engineering control, e.g. safer needlestick devices, sharps containers. This is followed by work-practice controls (universal precautions, no recapping) and administrative controls(policies and training programmes). Work practice controls should not be a substitute for engineering controls and should only be considered if the technology to eliminate or reduce the hazard is not yet available. Training measures, however, should complement all types of controls.

The last priority (and least effective) are individual control measures: personal protective equipment, such as gloves, masks, gowns, etc. (see also Protective clothing against chemical and biological hazards).


Elimination: alternatives to using needles

Different systems are available to eliminate unnecessary use of needles. Needle-free systems provide an alternative to needles for some procedures, reducing the risk of injury from contaminated sharps, e.g.:

  • Needle-free liquid jet injections: a high-speed jet is used to puncture the skin and deliver drugs without the use of a needle. They have been used to deliver vaccines and insulin, as well as anaesthetics and antibiotics [27]. Occasional pain and bruises have limited the acceptance of jet-injectors.
  • Needle-free intravenous medication systems: The system uses interlocking parts instead of needles connections. It delivers medication or fluids through a catheter by using non-needle connections. The connections can be plugged together without using a needle, and without opening the line and exposing the bloodstream.
  • Needle-free urine sampling.

Other measures to eliminate the use of needles:

  • Alternative routes for delivering medication and vaccination, e.g. oral medications (if available and safe for the patient).
  • Eliminating unnecessary punctures - a strategy that is good for both patients and healthcare personnel.


Isolation: Safety devices

Safety devices are designed to prevent workers being injured by contaminated needles or other sharps. They are equipped with safety features which prevent needlestick injuries (Tab. 2).

There are many different types of safer devices. They can be divided in two categories:

  • Active devices that require worker activation of the safety mechanism (sliding a protective shield over the needle after use).
  • Passive devices that work automatically (not requiring workers activation, e.g. retractable syringe).

Directive 2010/32/EU [23] stipulates that safety devices must be used were technically useful and safe for patients. Until now it has not been technically possible to use safety devices with premature babies [28]. There is evidence that the use of safe devices, when combined with training and safe work practice, can reduce the risk of needlestick injuries. A pilot-study to test different safe devices was carried out in 12 hospitals in Hamburg, Germany. The result showed that 84 % of the safety devices were useful and needlestick injuries could be reduced by 50% - 60% [29].

A French study [30] showed that passive safety devices were more effective in preventing needlestick injuries than active devices.

Healthcare staff must be involved in the implementation of new safety devices in hospitals, and the following criteria must be considered (adapted from Unison [31]):

  • The device must not compromise patient care
  • The device must perform reliably
  • The safety mechanism must be an integral part of the safety device, not a separate accessory
  • The device must be easy to activate and use
  • The activation of the safety mechanism must be convenient and allow the care-giver to maintain appropriate control of the procedure
  • The device must not create other safety hazards or sources of blood exposure
  • A single-handed or automatic activation is preferable


Various databases provide information and examples of safe medical devices: e.g. Safe devices database [32].


Table 2: Priorities for safety-engineered sharps

  1. Needleless IV systems
  2. IV catheters
  3. Winged blood collection sets
  4. Straight blood collection needles
  5. Hypodermic needles (including arterial blood gases)
  6. Lancets
  7. Sutures

Source: adapted from the Ontario Nurses’ Association [17]

Administrative and work practice control – safe work

Effective measures to prevent sharps injuries also include administrative and work practice controls [7][33]. These reduce the likelihood of exposure by changing the way work is done.

Administrative control measures include policies and programmes to limit the exposure to sharps injuries, e.g.:

  • Preparing a written statement of the health and safety policy.
  • Providing adequate staffing and adjusting work schedules.
  • Defining local health and safety policies to detail how safe working will be achieved on a day-to-day basis.
  • Defining/detailing clear health and safety responsibilities.
  • Implementing an incident reporting system.
  • Providing regular information and training.
  • Implementing vaccination programmes.


Training and accessible guidelines must be available for all workers (including new recruits, agency staff, self-employed and ancillary workers). Workers should be involved in decisions about safe working practices (see also OSH management systems and workers' participation).

Working practices controls aim to change the behaviour of the workers. Appropriate training is needed to ensure that all workers are aware of the risks of exposure to biological agents, and know about safe work procedures and the use of safe medical device, as well as standard operating procedures (see also OSH training).

Safer working practices include:

  • Use of safe medical devices.
  • Ban on recapping: Manual recapping leads to a high risk of being punctured by a needle. Re-capping is the practice of re-sheathing used needles. According to Directive 2010/31/EU [23] “the practice of recapping shall be banned with immediate effect.”
  • Safe disposal of used sharps and needles in appropriate containers (puncture resistant, leak proof and closable) [34]. Used needles and sharps must be disposed immediately after use.
  • Easy accessibility of appropriate sharps containers in the immediate vicinity where sharps and needles are used.
  • Regularly checking sharps containers (and exchanging if full).
  • No passing on of contaminated sharps and needles from one person to another.
  • Sharing information among all workers about risk situations (e.g. uncooperative or confused patients).
  • Immobilisation of sharps and needles before they are disposed of, e.g. by gypsum moulding.

Personal protective equipment (PPE) and vaccination

Personal protective equipment is the least effective control measure. PPE provides a barrier between the worker and the hazard. It can only prevent exposure to blood or other body fluids, but it cannot protect workers from sharps and needlestick injuries. It should only be used when workers’ exposure to sharps injuries cannot be eliminated by safe work practices and engineering controls (see also Protective clothing against chemical and biological hazards).

Examples of PPE are:

  • Gloves (cutting resistant gloves, double gloving)
  • Masks
  • Face shields
  • Protective glasses

To prevent occupational infections of healthcare workers from bloodborne pathogens, Directive 2010/32/EU [23] stipulates in clause 6 paragraph 4 that ‘Vaccination and, if necessary, revaccination shall be carried out in accordance with national law and/or practice, including the determination of the type of vaccines: — Workers shall be informed of the benefits and drawbacks of both vaccination and non-vaccination, — Vaccination must be offered free of charge to all workers and students delivering healthcare and related activities at the workplace.’

Hepatitis B vaccination is mandatory for medical, nursing and paramedical staff in five EU member states (Belgium, Czech Republic, France, Poland and Slovenia). It is recommended in the others [35].

Incident reporting

Sharps and needlestick injuries are highly underreported. According to a Swiss study, the highest level of non-reporting needlestick injuries is among doctors [36]. The main reasons identified were desensitisation (seeing injuries as "business as normal") and underestimating the real risk. According to a survey conducted by Diprose et al, only 34% of anaesthetists questioned were aware of the real risk of transmission of HIV from a needlestick injury [37]. The second reason given for not reporting was a lack of time >ref name="Voide" />.

It is, however, important to report injuries, so that appropriate treatment can follow without delay. Reporting injuries is also important for identifying the causes of an injury, and for taking the necessary measures to prevent further injuries.

What to do in case of an injury

If workers are contaminated with blood or other body fluids, they should take the following actions without delay [38][8]:

  • Wash splashes off their skin with soap and running water.
  • Wash out splashes in their eyes using tap water or an eye wash bottle. Wash nose or mouth with plenty of tap water. Do not swallow the water.
  • Wash cuts thoroughly under running water with soap, without scrubbing the wound.
  • Do not suck the wound.
  • If soap and water are not available, use alcohol-based hand rubs or solutions.
  • Encourage bleeding from the wound.
  • Cover the wound with a dressing.
  • Ensure the sharp instrument is disposed of safely.
  • Record the source of contamination.
  • Report the incident to the supervisor, line manager or health and safety adviser, and to the occupational health department or medical adviser if there is one.
  • Go straight to a doctor, or to the nearest hospital emergency department.
  • Check vaccination status.

Post Exposure Prophylaxis (PEP)

Immediate action is required in cases of accidental exposure to bloodborne pathogens through sharp injuries. This involves proper risk assessment, individual medical advice and consultation, and the prescription of post exposure prophylaxis (PEP), if appropriate PEP is unpleasant to take and may have side-effects and toxic effects. After exposure to Hepatitis B, active and passive immune-prophylaxis is an effective tool to prevent infection in non-vaccinated workers. Whilst there is no effective PEP available, an early interferon-monotherapy may reduce the risk of chronic illness. Recommended PEP after exposure to HIV includes two inhibitors of the reverse transcriptase and one inhibitor of the protease or one non-nucleoside reverse transcriptase inhibitor (NNRTI) [39].

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  32. Unfallkasse Nordrhein-Westfahlen (2009). Verzeichnis sicherer Produkte zum Schutz vor Nadelstichverletzungen (Safe devices to protect from needlestcik injuries). Retrieved 8 May 2012, from: http://www.infektionsschutz.gesundheitsdienstportal.de/nadelfilter/nadelfilter.htm
  33. Wilburn, S, ‘Needlestick and Sharps Injury Prevention’, Online Journal of Issues in Nursing. Vol. 9, No 3, 2004, pp. 5-8. Available at: http://www.zerobsi.com/bsi/docs/Wilburn_3AD0418.pdf
  34. NIOSH – National Institute for Occupational Safety and Health (US), (2011). STOP STICKS campaign: Sharps Injuries: Sharps Disposal. Retrieved 8 May 2012, from: http://www.cdc.gov/niosh/stopsticks/sharpsdisposal.html
  35. De Schryver, A., Claesen, B., Meheus, A., Sprundel, v. M., François, G., ‘European survey of hepatitis b vaccination policies for healthcare workers’. European Journal of Public Health. Vol. 21, No 3, pp. 338-343, 2010. Available at: http://eurpub.oxfordjournals.org/content/21/3/338.full.pdf+html
  36. Voide, C., Darling K.E.A., Kenfak-Foguena, A., Erard, V., Cavassini, M., Lazor-Blanchet, C., ‘Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital.’ Swiss Medical Weekly, 2012, pp. 1-7. Available at: http://www.smw.ch/scripts/stream_pdf.php?doi=smw-2012-13523
  37. Diprose, P., Deakin D.D., Smedley, J., ‘Ignorance of post-exposure prophylaxis guidelines following HIV needlestick injury may increase the risk of seroconversion’. British Journal of Anaestesia, 84 (6), (2000), pp. 767-770
  38. HSE – Health and Safety Executive, ‘Blood-borne viruses in the workplace.’ Guidance for employers and employees, 2009, pp. 1-7. Available at: http://www.hse.gov.uk/pubns/indg342.pdf
  39. Sarrazin, U., Brodt, H.-R., Sarrazin, C., Zeuzem, S.,‘Prophylaxe gegenüber HBV, HCV und HIV nach beruflicher Exposition.‘ Deutsches Ärzteblatt, Jg. 102, Heft 33, 2005. Available at: http://www.ifado.de/forschung_praxis/zentrale_einrichtungen/klinische_arbeitsmedizin/Intranetinformation/Hepatitis_Prophylaxe.pdf

Links for further reading

BG BAU- Berufsgenossenschaft der Bauwirtschaft (statutory accident insurance for construction), Reinigungsarbeiten mit Infektionsgefahr in medizinischen Bereichen (Protecting cleaners from infection risks in healthcare facilities), BGR 201, updated 2006. Available at: http://www.bgbau-medien.de/html/pdf/bgr/bgr_208.pdf

BGF – Berufsgenossenschaft für Fahrzeughaltungen (statutory accident insurance for transport), Biologische Arbeitsstoffe beim Umgang mit Verstorbenen (biological agents when handling with deceased), BGI 5026, 2009, Available at: http://publikationen.dguv.de/dguv/pdf/10002/bgi5026.pdf

BGFE - Berufsgenossenschaft der Feinmechanik und Elektrotechnik (Statutory accident insurance for precision and electrical engineering), Zahntechnische Laboratorien – Schutz vor Infektionsgefahren (Dental Laboratories – Protection against Risks of Infection), BGI 775, 2007. Available at: http://publikationen.dguv.de/dguv/pdf/10002/bgi775.pdf

CDC - Centres for Disease Control and Prevention (2011), STOP Sticks. Safety campaign. Retrieved 10 May 2012, from: http://www.cdc.gov/niosh/stopsticks/

HSE, Health and Safety Executive (UK), Handling needles in the waste and recycling industry, HSE/WISH document, Waste019, 2007. Available at: http://www.hse.gov.uk/pubns/waste19.pdf

HSE, Health and Safety Executive (UK ), Controlling the risks of infection at work from human remains, a guide for those involved in funeral services (including embalmers) and those involved in exhumation, 2005, Available at: HSE, http://www.hse.gov.uk/pubns/web01.pdf

ICN - International Council of Nurses, ICN on Preventing Needlestick Injuries, factsheet, Available at: http://www.icn.ch/images/stories/documents/publications/fact_sheets/19i_FS-Preventing_Needlestick_Injuries.pdf

NHS (National Health Service) Employers, Needlestick Injuries’, 28 April 2011, Available at: http://www.nhsemployers.org/Aboutus/Publications/Documents/Needlestick%20injury.pdf

Unfallkasse Nordrhein-Westfahlen (2009). Kleiner Stich mit Folgen. Retrieved 10 May 2012, from http://www.infektionsschutz.gesundheitsdienstportal.de/start/nadelfilter.htm

Unison, Needlestick injuries: a guide for local government safety representatives. Undated. Available at: http://www.unison.org.uk/acrobat/10840.pdf

Contributors

Ellen Schmitz-Felten