ASD Management

Leading Nationally

Assuring Compliance With OSHA’S Needle Safety Requirements

By Sandra Jones
Executive Vice President, ASD Management

This Q&A is due to be published by the Florida Society of Ambulatory Surgical Centers (, to which Sandra Jones is a regular contributor.


Question: What should I review to assure I am in compliance with OSHA’s needle safety requirements? I read that OSHA was receiving funding to inspect surgery centers in Florida and a few other states.

Answer: OSHA announced that it would visit a sampling of surgery centers, freestanding emergency care clinics and primary care medical clinics. Inspections will focus on blood-borne pathogen hazards associated with sharps devices. This “emphasis program” will begin April 25 and continue until September 30, 2012.

Can you feel the love? Does the attention to ASCs make you feel special? Certainly ASC administrators are not complaining about lack of attention from federally funded surveyors.

Ambulatory surgery centers have had policies, procedures and employee training in place for many years to comply with OSHA regulations and to assure a safe environment for patients and staff. Annual education on blood-borne pathogen exposure, action when an exposure occurs and use of personal protective equipment and engineering control are part of ongoing programs for sharps injury prevention. But with this increase in OSHA inspections, now would be a good time to review your employee education materials, policies and procedures, and sharps injury prevention program.

There is an excellent tool available from the Centers for Disease Control (CDC), to help assure your program is up to date. Go to to download “Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program.” The introduction states that CDC specifically designed the workbook to help facilities prevent needle stick and other sharps-related injuries.

The publication contains helpful worksheets, checklists and assessment tools. There are examples of monitoring tools and discussion of how results are incorporated into performance improvement activities. Although written to encompass program elements in various types and sizes of healthcare organizations, the workbook provides fundamentals that anyone can use regardless of the facility activity, volume or complexity.

Take your internal inspection one step further by having someone else on your staff review policies and practices. The effort can provide a different opinion or insight that can make your policies and practices better. Consider assigning one of your staff to review the CDC Workbook, compare to your policies, judge against practices and help plan monitoring and educational tools. Set up monitoring, develop a report, research injuries or near misses to analyze what may have been done differently to increase safety, determine and implement an action plan, and then re-assess to determine if the action worked.

There it is: a sharps injury prevention program that meets requirements and is integrated into your quality assessment/performance improvement (QAPI) program.

Come on surveyors; we are always ready!

Avoid Medicare Surveyor Citations of Deficiency in Your Governing Body Minutes Key Factors to Turnaround ASC Operations
Avoid Medicare Surveyor Citations of Deficiency in Your Governing Body Minutes
Key Factors to Turnaround ASC Operations

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