Included in the Centers for Disease Control and Prevention’s “Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program” is a form for the surveying of device use. The information from this survey helps product evaluation teams identify the device-specific issues they must consider when selecting substitute products. Department heads, nursing units or their designees should complete this form.
To download this CDC-developed survey of device use, which includes a sample cover memo, for adaptation and use in your facility, click here (pdf). The example uses a hypodermic needle/syringe. The form will need slight modification if used for other types of devices, but the questions will be similar, if not the same.
Download other patient safety-related tools and resources:
– Sample Surgical Wound Classification Form
– Sample Hand Hygiene Observation Record
