Bloodborne Pathogens Exposure & Needlestick Response
Occupational exposure to blood or other potentially infectious materials (OPIM) requires an immediate, standardized response to protect employees, reduce the risk of infection, and ensure compliance with OSHA Bloodborne Pathogens Standards.
Purpose
This SOP establishes the required response following an occupational exposure, including needlestick injuries, sharps injuries, or contact with blood or other potentially infectious materials.
Every exposure must be treated seriously, reported immediately, medically evaluated, and documented according to clinic policy and OSHA requirements.
Responsibilities
Employees
Immediately perform first aid, report the exposure, participate in medical evaluation, and complete required documentation.
Supervisors
Ensure immediate medical evaluation is arranged, secure incident information, and initiate the reporting process.
Leadership / HR
Coordinate OSHA compliance, maintain confidential records, and ensure required follow-up is completed.
Providers
Evaluate the exposure, provide clinical guidance, and determine appropriate post-exposure recommendations.
Immediate Exposure Response Workflow
Stop the Procedure Safely
Secure any sharps, ensure patient safety, and discontinue the procedure if it can be done safely.
Perform Immediate First Aid
Wash needlestick or skin exposures thoroughly with soap and water. Flush splashes to the eyes, nose, or mouth with copious amounts of water or saline according to clinic policy.
Notify Leadership Immediately
Report the exposure to your supervisor or designated leader without delay.
Arrange Medical Evaluation
Promptly initiate the clinic's post-exposure evaluation process according to organizational policy.
Preserve Relevant Information
Document the circumstances of the exposure, including the activity being performed, the type of exposure, and the device involved, when applicable.
Complete Initial Documentation
Begin all required incident documentation before the end of the work shift or as soon as reasonably possible.
Post-Exposure Evaluation & Follow-Up
Following an occupational exposure, prompt medical evaluation, appropriate documentation, and confidential follow-up are essential to protecting employee health and maintaining regulatory compliance.
Employees experiencing an exposure should complete all required medical evaluations, laboratory testing, and follow-up appointments according to clinic policy and the recommendations of the evaluating healthcare provider.
• Immediate medical evaluation.
• Baseline testing when indicated.
• Completion of recommended follow-up appointments.
• Confidential management of employee health records.
• Documentation of all actions taken.
Exposure Risk Assessment
Exposure Type
Document whether the exposure involved a needlestick, sharps injury, splash to mucous membranes, non-intact skin, or another occupational exposure.
Source Material
Identify the type of potentially infectious material involved and document the circumstances surrounding the exposure.
Incident Details
Record where, when, and how the exposure occurred to support quality improvement and future prevention efforts.
Medical Follow-Up
Follow organizational policy for post-exposure evaluation and any recommended medical monitoring.
Sharps Injury Prevention
Preventing occupational exposure is a shared responsibility. Employees should consistently follow Standard Precautions, use safety-engineered devices when available, and dispose of sharps immediately after use.
Engineering Controls
Use approved safety devices and sharps containers as designed. Report damaged or malfunctioning equipment immediately.
Safe Work Practices
Handle sharps carefully, maintain awareness of your surroundings, and minimize unnecessary hand-to-hand passing of sharp instruments.
Sharps Disposal
Dispose of used needles and other sharps immediately into an approved sharps container located as close as practical to the point of use.
Documentation & Reporting
Complete the Incident Report
Complete all required organizational incident reporting forms as soon as possible following the exposure.
Notify Appropriate Departments
Ensure leadership, Human Resources, and any other required departments are notified according to clinic policy.
Participate in Follow-Up
Attend recommended follow-up evaluations, laboratory testing, or occupational health appointments as directed.
Review for Prevention
Leadership should review the incident to identify contributing factors and implement improvements that reduce the risk of future occupational exposures.
Do & Don't
✔ Always
• Perform immediate first aid.
• Report exposures immediately.
• Complete required documentation.
• Participate in medical follow-up.
• Dispose of sharps safely.
• Report unsafe conditions.
✖ Never
• Delay reporting an exposure.
• Ignore a needlestick injury.
• Recap used needles unless required by an approved one-handed technique or device-specific instructions.
• Dispose of sharps in regular trash.
• Share confidential medical information outside authorized personnel.
Employee Competency
- Recognizes occupational exposure events immediately.
- Performs appropriate first aid following an exposure.
- Reports incidents promptly according to clinic policy.
- Demonstrates proper sharps handling and disposal techniques.
- Completes required documentation accurately.
- Participates in post-exposure medical evaluation and follow-up.
- Applies Standard Precautions consistently.
- Supports a culture of workplace safety and prevention.