IN THE SEPTEMBER issue of Nursing2003, readers were invited to participate in a needle-stick and sharps-safety survey. A total of 498 nurses responded to the questions, providing insightful comments about the availability and utilization of safety-engineered devices.

The survey results reflect progress in implementing safety devices and preventing sharps injuries in the health care workplace, and provide information about areas of noncompliance. The results also underscore the need for ongoing efforts in implementing safety technology for all procedures where it's available and appropriate and for continued vigilance in monitoring compliance.

Of the 498 survey respondents, most work in hospitals (60%). Other settings significantly represented include long-term care (13%), home health care (8%), offices (6%), and outpatient/clinics (5%).

As you review the survey results we summarize in these pages, keep in mind that survey participants were self-selected and not necessarily representative of all nurses. For example, nurses who recently sustained a needle stick or other sharps injury might have been more motivated to participate, which would introduce a bias in the results.

1. How many sharps injuries have you sustained in the last year?

0[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]76%

1-2[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]21%

3-4[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]2%

5 or more[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]1%

Nearly a quarter (24%) of respondents report one or more sharps injuries in the previous year. Statistically, this indicates a minimum of 0.24 sharps injury per nurse per year.

The average rate for health care workers in general is 0.18 sharps injury per health care worker per year, according to a survey funded by the National Institute of Occupational Safety and Health involving six hospitals in the United States.

2. If you sustained one or more sharps injuries in the last year, answer questions 2a through 2f in relation to your most recent injury.

2a. Your most recent injury was caused by a device used for

intramuscular, intravenous (I.V.), or subcutaneous injection[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]50%

blood drawing[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]16%

injection into I.V. tubing port[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

heel sticks/finger sticks (lancet)[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

I.V. catheter insertion[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]5%

suturing (suture needle)[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]2%

cutting (scalpel)[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]1%

other[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]12%

2b. Did the sharps device have a safety design (for example, a shielded, recessed, retractable, or blunted needle or blade)?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]54%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]46%

2c. Did the injury occur

during medication preparation[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]33%

after use of the device[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]23%

during use of the device[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]19%

while disposing of the device[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]18%

during activation of the safety mechanism[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

To investigate differences in injury patterns between those injured by safety devices and those injured by conventional devices, we divided respondents into two groups: those who answered yes to question 2b and those who answered no. We then compared the responses from the two groups for questions 2a and 2c.

More than half of respondents who sustained a sharps injury in the previous year reported being injured by a device with a safety design. Does this mean safety devices aren't "working"? No. These responses can't be used to gauge the effectiveness of safety devices because of the potential bias we previously noted. More important, we can't calculate a device-specific injury rate because we don't have data on how many safety devices were used in total (including those not involved in an injury). Furthermore, the increase in the number of injuries involving safety-engineered sharps reflects the increase in safety-device use in health care settings. The greater the number of safety devices in use, the greater the chance that injuries will occur with them.

Most safety-engineered sharps devices help prevent injuries after-not during-their use, so injuries during use can still occur. Also, the user may not activate the safety feature, rendering it ineffective.

When we examined injuries associated with the procedures listed in question 2a, we found the following:

* 58% of injuries in the safety-device group occurred while the nurse was giving an intramuscular, I.V., or subcutaneous injection, compared with 40% in the conventional-device group.

* 8% of injuries in the safety-device group involved I.V. catheter insertion, compared with 2% in the conventional-device group.

* 13% of injuries in the safety-device group occurred while drawing blood, versus 18% of injuries in the conventional-device group.

* 5% of injuries in the safety-device group occurred while injecting into an I.V. port, versus 10% in the conventional-device group.

* When we examined injuries according to where in the device-usage process the injuries occurred (question 2c), we found that:

* 25% of injuries in the safety-device group occurred during use of the device, compared with 12% of injuries in the conventional-device group. This makes sense because many safety devices provide protection after use, not during use when the needle is exposed. Because a smaller fraction of total injuries involving safety devices occurs after use, the proportion of during-use injuries is higher.

* 18% of injuries in the safety-device group occurred after use of the device, compared with 30% in the conventional-device group.

* 12% of injuries in the safety-device group occurred during activation of the safety mechanism and 15% occurred during disposal. Of injuries related to conventional devices, 22% occurred during disposal.

Based on respondents' comments, failure to activate the safety feature is a significant factor. This underscores the need for thorough training in the correct use of safety devices, with follow-up and monitoring to ensure that nurses are using the protective features on safety devices.

2d. Did you report your most recent injury to your institution?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]58%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]42%

The proportion of respondents who say they didn't report their injury is somewhat lower than the most recent Centers for Disease Control and Prevention rate for sharps injury underreporting among nurses, which was 47%. More nurses in the 21-to-30 age-group (59%) say they didn't report their most recent injury than those in the 41-to-50 age-group (33%)-a surprising finding that underscores the need for more early education in sharps safety.

2e. If the sharps device had been used on a patient infected with human immunodeficiency virus (HIV), did you receive postexposure prophylaxis (PEP)?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]15%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]85%

When an employee is exposed (or potentially exposed) to an HIV-positive patient, both the patient and the employee should be tested, the transmission risk evaluated (taking into account the circumstances of the exposure), and PEP offered if indicated. The high percentage of respondents who say they didn't receive PEP may mean that most of these exposures were in the low-risk category; for example, the injury didn't involve a device used for accessing a patient's vein or artery. Regardless of the circumstances, however, all HIV exposures should be thoroughly evaluated and followed up.

2f. If you received PEP, did you miss any work because of adverse reactions related to the drugs?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]0%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]100%

3. To the best of your recollection, what percentage of needles or sharps you used in the past year was safety-engineered (for example, shielded, recessed, retractable, or blunted needles or blades)? [spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]68%

Responses to question 3 revealed that, on average, 68% of needles and sharps used by respondents are safety-engineered. One-fifth (20%) of respondents say they use only safety-engineered sharps devices.

4. Which of the following best describes the extent to which your institution provides safety-engineered sharps devices?

for all or most patient-related procedures[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]60%

for some, but not all, procedures[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]27%

for few procedures[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]6%

never[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

Does the use of safety devices help reduce sharps injury rates? To see if the survey data could provide insight on this question, we divided responses to question 4 into two groups: those who say they used safety devices for all, most, or some procedures and those who say they used them for few or no procedures. We then compared the two groups' responses to the responses to question 1 ("How many sharps injuries have you sustained in the last year?").

The results: In the group that reports using safety devices frequently or all the time, 21% say they sustained one or more sharps injuries in the previous year. For those who seldom or never use safety devices, that percentage was almost double-41%. These data suggest that safety devices are associated with reduced sharps injury rates.

Yet responses to question 4 also indicate that, in at least 1 in 10 health care facilities, safety devices are used infrequently or not at all.

The Needlestick Safety and Prevention Act was passed and the Revised Bloodborne Pathogens Standard was implemented 3 years ago. Although progress has been made in implementing safety devices and providing better protection for health care workers since then, these data show that in many work settings the safety conversion process is far from complete.

5. How do you rate the training you received for the safety-engineered sharps devices you use in your practice?

adequate training[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]70%

inadequate training[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]11%

no training[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]13%

not applicable; don't use safety devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]6%

Although most respondents say they had adequate training, almost one in four indicates inadequate or no training. A larger proportion of hospital-based participants (72%) report receiving adequate training compared with home health care participants (51%).

6. What's your opinion of safety-engineered needles and sharps devices?

I prefer safety-engineered devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]78%

I prefer non-safety-engineered devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]8%

I have no preference[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]10%

I don't have access to safety devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]5%

Approximately four out of five nurses say they prefer using safety-engineered devices. All devices have some limitations, including safety devices. But overall data on safety devices show that they're effective in reducing sharps injuries. Device manufacturers are constantly refining the designs of safety devices, so it's important to keep abreast of new technology and evaluate new devices to see if they're easier to use than the ones currently available.

7. Are non-safety-engineered (conventional) sharps devices still readily available in your institution?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]64%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]29%

don't know[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

Responses to this question indicate that, even though safety devices are in widespread use in most U.S. health care institutions, conventional devices are also still widely available. Suture needles are the single largest device category in which conventional designs continue to be used for most procedures (see Blunt Talk about Suture Needles). In addition, in many facilities, safety and conventional versions of a device-for example, I.V. catheters-are stocked side by side, and it's left up to the clinician to decide which to use. Unless facilities can provide written justification for using conventional devices (based on a patient-safety issue), the Occupational Safety and Health Administration (OSHA) requires that safety, and safety only, be implemented in all device categories where safety alternatives are available.

8. Does your institution solicit input from nurses who care for patients in selecting safety-engineered devices?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]54%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]29%

don't know[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]17%

The Occupational Safety and Health Administration also requires facilities to include front-line health care workers when selecting and evaluating safety devices, yet close to 50% of the survey's respondents say either they don't have input or they don't know if their institution solicits nurses' input.

9. Do you feel your institution is committed to providing a safe working environment in terms of sharps safety?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]87%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]13%

More than twice as many home health care nurses say their institution is not committed to providing a safe working environment, compared with those in hospital settings (24% versus 11%).

10a. Does your facility maintain a sharps injury log?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]47%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]9%

don't know[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]44%

Since the Revised Bloodborne Pathogens Standard took effect in 2001, OSHA has required institutions to keep a sharps injury log. At a minimum, these logs must contain the type and brand of device that caused the injury (if known), the department or work area where the injury occurred, and an explanation of how the injury occurred.

10b. If yes, does your facility regularly share sharps injury data and information on recent sharps injuries for education and injury prevention?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]61%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]20%

don't know[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]20%

Many facilities have found that sharing sharps injury data with staff is an effective way to educate them about injury patterns and prevention strategies. A computer-based sharps injury surveillance program such as EPINet (Exposure Prevention Information Network) allows facilities to run injury reports by individual department or clinical setting. This is especially helpful in areas such as the operating room, where injury patterns may reflect specialized devices or procedures.

11. What kinds of sharps injury training and protocols does your institution provide? (Check all that apply.)

proper handling and disposal of sharps devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]66%

procedures for reporting a sharps injury[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]60%

postexposure follow-up, including PEP when appropriate[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]60%

training on newly introduced sharps devices[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]53%

routine maintenance of disposal containers[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]50%

no sharps injury prevention training provided at my facility[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]12% These findings indicate a need for improved education regarding safety-engineered sharps devices, injury prevention, and postexposure protocols.

12. Would you say that implementation of safety devices has made your institution

a much safer place to work[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]42%

a somewhat safer place to work[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]43%

no safer than before[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]7%

not applicable; no safety devices in our institution[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]8%

These responses indicate that safety devices may contribute to nurses' sense of personal safety in a hazardous work environment. But 50% of respondents say that safety devices make their workplace only "somewhat safer" or "no safer." Such answers may reflect a low comfort level with using safety devices because of lack of training or experience. The small but significant number of nurses who indicate that their facilities don't provide safety devices is a reminder, once again, that many nurses don't have the protection afforded by these devices.

13. If you were considering accepting a new job at a health care facility, would the potential employer's sharps-safety record and its policy regarding use of safety devices in that facility be significant factors in your decision?

yes[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]55%

no[spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above][spacing dot above]45%

Given the current nursing shortage, this finding sends an important message for all health care employers. Nurses are looking for a commitment to safety.

Preventing the preventable

Needle sticks and other sharps-related injuries continue to be an important public health concern. These types of injuries are largely preventable with the proper use of safety-engineered devices, yet data from this survey show that many nurses have little or no access to safety devices or to training in using them correctly.

These survey results highlight the need for nurses to be "safety champions," actively participating in the safety conversion process and letting management know their safety concerns. Efforts to prevent sharps injuries can succeed only if those with a vested interest-nurses, health care facilities, and manufactur-ers-collaborate in the development and proper use of safety-engineered devices.

WHAT RESPONDENTS HAD TO SAY

In extra comments they provided about their experiences, many survey respondents expressed concerns about:

* safety features that don't stay in place during use, accidentally activate, or are difficult to activate. While preparing an antibiotic for I.M. injection, one nurse was stuck because "the retractable sheath on the syringe slipped while I tried to inject diluents into the medication bottle." Another said that "I had to push the plunger very hard to get [the needle] to retract; I feel too much force is required [to activate the safety feature]".

* glass ampules that can shatter and cause sharps injuries. One nurse said that they're "the most potentially dangerous piece of equipment for nurses." Some respondents suggested that more medications be prepackaged in syringes instead of in vials and ampules to avoid the need to draw up medication using needles.

* nonstandardized safety features on prefilled syringes. Commented one nurse, "It is confusing when, in one med pass, I can encounter three or four different safety mechanisms."

BLUNT TALK ABOUT SUTURE NEEDLES

Suture needles are the leading cause of sharps injuries in ORs (accounting for 41% of sharps injuries in that setting) and the second leading cause of sharps injuries in hospitals overall. One safety alternative, blunt-tip suture needles, are sharp enough to pierce internal tissue, such as muscle and fascia, but generally not sharp enough to pierce skin. Although not suitable in all circumstances, they could reduce suture-related injuries by as much as a third if used appropriately-yet they still haven't been adopted by most surgeons.

Selected references

Centers for Disease Control and Prevention: "Evaluation of Blunt Suture Needles in Preventing Percutaneous Injuries among Health-Care Workers during Gynecologic Surgical Procedures-New York City, March 1993-June 1994," JAMA. 277(6):451-452, February 12, 1997.

Jagger, J., and Perry, J.: "Comparison of EPINet Data for 1993 and 2001 Show Marked Decline in Needlestick Injury Rates," Advances in Exposure Prevention. 6(3):25-27, 2003.

Jagger, J., et al.: "Occupational Exposure to Bloodborne Pathogens: Epidemiology and Prevention," in Prevention and Control of Nosocomial Infections, 4th edition, R. Wenzel (ed). Baltimore, Md., Lippincott Williams & Wilkins, 2003.

Jagger, J., et al.: "A Study of Patterns and Prevention of Blood Exposures in OR Personnel," AORN Journal. 67(5):979-996, May 1998.

Panlilio, A., et al.: "Estimate of the Annual Number of Percutaneous Injuries in U.S. Healthcare Workers," Infection Control and Hospital Epidemiology. 21(2):157, February 2000.

Perry, J.: "Improving Your Sharps Safety Program," Outpatient Surgery Magazine. 4(9):94-96, September 2003.