Preventing Bloodborne Pathogen Violations in the ASC: Q&A With AORN's Mary Ogg

In a recent report, the Occupational Safety and Health Administration listed the most frequently cited bloodborne pathogen violations in surgery centers. According to the report, OSHA has increased medical facility inspections in the last several years, meaning citations for bloodborne pathogen violations are on the rise in ASCs and physician offices.

Such violations made up the majority of OSHA medical citations in recent years — a significant cause for concern, since violations can expose patients and healthcare workers to serious diseases such as HIV and hepatitis B and C. Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist with AORN, discusses how bloodborne pathogen violations occur and what ASC providers can do to avoid violations in their facilities.

Q: Why do bloodborne pathogen violations constitute such a high percentage of medical facility citations?

Mary Ogg: The Bloodborne Pathogens Standard, 29 CFR 1910.1030, is the most frequently cited OSHA standard in healthcare. As to why it is the most frequently cited standard, it may be the broad scope it encompasses. The standard applies to all occupational exposures to "blood or other potentially infectious materials (OPIM)."

Q: What are the main causes behind these violations? How can facilities take action to prevent them?

MO: The most frequently cited paragraphs of The Bloodborne Pathogens Standard 29 CFR 1910.1030 since the passage of the Needlestick Safety and Prevention Act in 2000 are: engineering and work practice controls, annual update of the exposure control plan, documenting annual considerations of sharps with engineered sharps injury prevention (SESIPs), sharps injury log and accessibility to regulated waste containers.

Engineering and work practice controls are primary controls that can eliminate or minimize a hazard and must be used:

SESIPS-engineering controls:
  • Examples of specialized surgical equipment include safety scalpels and blunt-tip suture needles, which provide a safer alternative to traditional sharp-tip suture needles.
  • No one device is appropriate for all uses. Device selection may differ depending on procedures.
  • Evaluation of devices should involve a mixture of staff members.

Work practice controls:
  • Providers should practice double-gloving.
  • Providers should use a predetermined "neutral zone" for placing or retrieving used sharps.
  • One-handed or instrument-assisted suturing technique should be used to avoid contact with the needle.

Exposure control plan-annual update:
  • The exposure control plan is a key provision of the bloodborne pathogens standard because it requires the employer to identify the employees who will receive the training, protective equipment, vaccination and other protections of the standard.
  • Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards-OSHA Publication 3186:
  1. Available from OSHA Publications Office or on OSHA Web site at
  2. Can be used as a template
  3. Must be made specific to each workplace
  4. Contains all elements required in the plan.
  • Must be reviewed every year

Documentation of annual considerations of SESIPs
  • Safety devices must be reviewed and evaluated yearly by front line users of the device.
  • Workers must be responsible for direct patient care and be potentially exposed to injuries from contaminated sharps.
  • The solicitation of employees who have been involved in the input and evaluation process must be documented in the exposure control plan.
  • A key element in choosing a safer medical device — other than its appropriateness to the procedure and its effectiveness — is its availability on the market.
  • If there is no safer option to the medical device that you are using for a particular procedure, you are not required to adopt a device different from the one currently being used.
  • With advances in medical technology, more devices are becoming available for different procedures. If no engineering control is available, work practice controls shall be used, and if occupational exposure still remains, personal protective equipment must also be used.

Sharps injury log-recordkeeping:
  • Facilities should maintain a log of occupational injuries and illnesses under 29 CFR Part 1904.
  • Facilities should maintain a sharps injury log for recording percutaneous injuries from contaminated sharps:
  1. Sharps injury log must contain, at a minimum, the type and brand of device involved in the injury (if known), the department or work area where the exposure incident occurred and an explanation of how the incident occurred.
  2. Injuries must be recorded and maintained in a manner that protects the confidentiality of the injured worker (e.g., removal of personal identifiers).
  • Forms
  1. OSHA Form 300 — Log of Work-Related Injuries and Illnesses
  2. OSHA Form 301 — Injury and Illness Incident Report
  3. OSHA Form 300A — Summary of Work-Related Injuries and Illnesses
  • Use data as a device for surveillance

Accessibility to regulated waste containers:
  • Sharps containers must be closable, labeled/color coded, leak proof, puncture resistant
  • Waste containers must be located close to the point of use (e.g., anesthesia cart, OR use)
  • Waste containers must be maintained upright
  • Waste containers must be replaced routinely and not allowed to overfill
  • Waste containers must be an adequate size to accommodate large disposable instruments, such as trocars and graspers

Q: What should training around bloodborne pathogen violations involve?

MO: Before employees can be trained on the bloodborne pathogens, the employer should become knowledgeable about all facets of the BBP standard-hazard evaluation, record keeping, hepatitis B vaccinations, hepatitis B declination forms and recordkeeping and responsibility to provide personal protective equipment.

Training for BBP violations should be specific to the violation and [discuss] why it is important to follow the standard. The standard's purpose is to protect the worker and indirectly our patients from exposures and injuries. The educational PowerPoint in AORN's Sharps Safety Tool Kit includes the evidence for using engineering and workplace controls such as double-gloving, neutral zone and blunt suture needles.

[Facility leaders should] include facility examples of sharps injuries and their consequences and perform a root cause analysis with the staff of why the injury occurred and what could be done in the future to prevent it. Make the training pertinent to the employees in your facility and their specific job functions. For example, blunt suture needles and the neutral zone are not relevant to PACU nurses, but safety needle and syringes and needleless connector systems would be.
Involving front line users of SESIPs in the selection and trialing of the products may increase acceptance and use of the products.

Q: What is the potential effect of bloodborne pathogen violations — both in terms of safety and accreditation issues?

MO: Violations of the BBP standard put the worker and potentially the patient at risk for transmission of HIV and hepatitis B and C. Additionally, the worker is at risk for injuries from scalpels, needles and other surgical items.

[In regards to accreditation], I cannot speak for the accrediting agencies and would advise checking with the individual accrediting bodies … to see if they check the public record for a facility's violations before inspections or if a violation would trigger an inspection. During their inspection process, a citation may be discovered during employee interviews or as part of document and process reviews.

Access More Resources on Bloodborne Pathogen Violations:

OSHA Compliance Assistance Tools
- OSHA Compliance Instruction - CPL 02-02-069 (explains policies and compliance procedures)
- Letters of interpretation (spell out, discuss and clarify new policies and applications)
- Safety and Health Information Bulletin (SHIB on blunt-tip suture needles)
- OSHA consultation services
- OSHA's website

AORN Tools
- Sharps Safety Tool Kit
- Previously recorded webinars

Learn more about AORN.

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