Introduction
Job hazard analyses (JHAs), otherwise known as job safety analyses, entail the systematic evaluation of each specific job task and the identification of the inherent occupational safety or health hazards associated with that task in addition to the specification of a control for the hazard. One might argue that the main intention of a JHA is to educate a job description in order to improve training, and more clearly specify responsibility for safety while on the job. As a result, JHAs can better protect workers from hazards inherent in their jobs. However, job hazard analyses should not be completed on job descriptions that are too broad (i.e., "helping sick people") or on job descriptions that are too narrowly defined (i.e., "retrieving a pillow").

In the health care industry, conventional wisdom holds that too often, nursing job descriptions are not developed without adequate integration of occupational health and safety imperatives. In other words, we suspect that JHAs are not often completed for nurses, and are therefore not often used to improve nursing job descriptions or training. As a consequence, nurses often become sick or injured while performing their jobs exactly as they've been trained to. For instance, occupational morbidity among nurses includes cumulative trauma disorders due to general ergonomic deficiencies and improper patient transfer techniques and strategies, blood borne pathogen exposures due to improper needle or sharps handling or proper use of defective devices, hazard communication violations due to multiple and consistent exposures to many toxic chemicals and unmanaged occupational stress. Together, these modifiable risk factors account for hundreds of millions of dollars per year in lost productivity and revenue for health care institutions. Consider:

• The health care industry is the second fastest growing sector in the US today, employing more than 12 million workers (www.cdc.gov/niosh/healthpg.html, accessed 8/9/03).
• Unlike other hazardous industries such as agriculture and construction, preventable injury rates in health care have increased over the past decade (www.cdc.gov/niosh/healthpg.html, accessed 8/8/03).
• Many OSH issues in the health care industry could be characterized as having substantial behavioral & process components. This provides a clue as to how we train OSH practitioners to better mitigate both frequency & severity of each hazard.

Purpose
This paper will focus on needlestick injuries (NSIs) among nurses in the health care industry as well as the mitigation of NSIs by use of safer needle technology. To better place the urgency of more study regarding safer needle devices, consider the brief analysis below:

Assume the costs of post-exposure prophylaxis (PEP) can range from $500-$1,000 per needlestick injury. If one assumes a conservative estimate for both the frequency of NSIs at 600,000/year and for the cost of PEP at $500/event, one finds that NSIs may cost an estimated $300,000,000/year.

Further, in well-designed studies, injuries from contaminated needles and other sharp devices used in health care settings have been associated with transmission of more than 20 different bloodborne pathogens to health care workers (Chiarello, 1992). Of these, HIV, HBV and HCV comprise the greatest risk to health care workers (Ippolito et al., 1997).

Clearly, from both a financial perspective as well as a labor availability perspective, it becomes imperative for health care organizations to optimize the safety and health of their working environment. Toward this end, safer needles should be considered a widely available engineering control that is effective in reducing risk to nurses. Indeed, the CDC determined in a 1997 study that blunt suture needles reduced NSIs by 86% and safer phlebotomy needles reduced NSIs to phlebotomists by 27%-76% (MMWR, 1997).

Characteristics of Needlestick Injuries (NSIs)
The most recent estimate of the number of needlestick injuries per year among healthcare workers in the US is found in the Needlestick Prevention Act, PL 106:430 (NPA) of 2000. The NPA modified the occupational exposure to bloodborne pathogens standard, 29 CFR 1910:1030. Among several things, the NPA modified the definition of an engineering control found in 1910.1030 to read: {an engineering control} "… means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace." Further, the employer must now evaluate safer needle devices, train employees on the safe use and disposal of safer needle devices and implement appropriate engineering controls as a part of the exposure control plan.

OSHA estimated that the NPA would reduce NSIs among health care workers by between 62 and 88% (OSHA news release USDL: 01-26) was a legislative addendum to the blood borne pathogen standard estimates that there are between 600,000 and 800,000 needlesticks per year.

According to EpiNet data from the University of Virginia, RNs and LPNs are clearly at most risk of needlesticks absorbing 49.7% of all sticks.

According to Ippolito, et al., 1997, most NSIs occur when using syringes.

Clearly, not every needlestick injury is preventable, but research has shown that almost 83% of injuries from hollow bore needles can be prevented (Ippolito et al, 1997). Indeed, most NSIs are caused by unsafe devices rather than by operator error (Jagger, 1988). Many of these needlesticks can be prevented by using devices which have needles with safety features or eliminate the use of needles altogether (e.g., needleless IV systems, self re-sheathing needles, blunted phlebotomy needles, and blunted surgical needles).

According to Jagger (1988), current NSI research is often hospital-based. NSI studies have indicated that a significant portion of needlestick injuries occur when manipulating IV lines or administering IV and IM injections as well as after use and before disposal. In fact, as long ago as 1992, the FDA published a safety alert regarding the use of hypodermic needles as a connection between two pieces of IV equipment. The FDA said that secondary IV tubing with connector needles was associated with the highest risk of needlestick injury. The FDA encouraged the use of needleless IV systems or systems with recessed needles to connect adjoining equipment.

Available Technology to Reduce the Risk of Needlesticks Among Nurses
Conventional wisdom would indicate that neither personal protective equipment nor administrative controls are effective strategies in the reduction of NSIs. Hence, to most effectively prevent exposure to the sharp or needle, engineering controls are indicated. Regarding NSIs, safer needle devices are the most logical form of engineering controls. In fact, the NPA strongly states that engineering controls be used to reduce NSIs. "Safer needle devices" is admittedly a broad term and includes devices that sheath the needle, or that do not use a needle at all. Generally speaking, the FDA (1995) has recommended that design features which describe a safer device will have the following characteristics:

> Provide a barrier between the operator's hands and the needle after use
> Will allow the operator's hands to remain behind the needle at all times
> Be an integral component of the device, and not an accessory
> Provide protection before, during and after use and after disposal
> Be simple and self-evident to all operators and require little training and no particular expertise

According to Chiarello (1995), there are at least four categories of safer device features. Safer devices may have:

1. passive safety features - safety features that remain in effect before, during and after use, the operator does not need to "activate" the safety feature
2. active devices - are features that require the operator to activate the safety mechanism, and failure to do so leaves the operator unprotected
3. an integrated safety design - a device has the safety feature included into its design and it can not be removed or inactivated. This is the preferred safety feature.
4. an accessory device- is a safety feature that is external to the device itself and therefore it must be fixed to the device at the point of use.

The following figures of currently available safer devices are found in OSHA's 2001 outreach and education effort presentation (www.osha.gov).

An example of a self sheathing needle is given in the figure below:

An example of a retractable hypodermic syringe:

An example of a self-blunting phlebotomy needle:

"Add ons" to syringes and blood tube holders are also available:

Retracting lancets include:

Before	During	After	Before	During	After

Disposal scalpels include:

Research Priorities
Although the NPA brought new attention and real legal enforcement to the NSI problem in the US, and although there are several new technologies available to health care workers, there is still much we don't know.

The NPA provides an opportunity to empirically test the efficacy of a piece of public health and safety legislation. Since the most current estimate of the number of NSIs among health care workers is already several years old, there is a need to determine a current estimate for the:

>Frequency of percutaneous needlestick injuries in hospital & non hospital settings.

>Costs of post exposure prophylaxis associated with a NSI.

Next, testing the efficacy of the NPA might include the following steps:

1. Compare frequency data for '01 & '02 by region and health care setting to pre NPA data.
2. Estimate costs of implementation of NPA, and compare morbidity costs pre NPA to post NPA and perform a cost benefit analysis.
3. Revise the NPA in light of the above analysis.

References

Centers for Disease Control and Prevention. "Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures." MMWR Recommendations and Reports. 40(RR-8): 1-9, 1991.

Centers for Disease Control and Prevention. "Evaluation of Safety Devices for Preventing Percutaneous Injuries Among Health care Workers During Phlebotomy Procedures - Minneapolis, St. Paul, New York City, and San Francisco, 1993-1995." MMWR. 46(2): 21-29, 1997.

Centers for Disease Control and Prevention. A Evaluation of Blunt Suture Needles in Preventing Percutaneous Injuries Among Health Care Workers During Gynecological Surgical Procedures - New York City, March 1993-June 1994". MMWR. 46(2): 29-33,1997.

Chiarello, L.A. "Selection of Safer Needle Devices: A Conceptual Framework for Approaching Product Evaluation". American Journal of Infection Control. 23( 6):386- 395, 1995.

FDA. "Needlestick and Other Risks From Hypodermic Needles on Secondary I.V. Administration Sets-Piggyback and Intermittent I.V." FDA Safety Alert. April 16, 1992.

Ippolito, G., Puro, V., Petrosillo, N., Pugliese, G., Wispelwey, B., Tereskerz, P. M., Bentley, M., & Jagger, J. Prevention, Management, and Chemoprophylaxis of Occupational Exposure to HIV. Charlottesville, VA: Advances in Exposure Prevention, International Health Care Worker Safety Center, 1997.

Jagger, J. "Rates of Needlestick Injury Caused by Various Devices in a University Hospital". N England J Med. 319(5): 284-8, 1988.

Jagger, J. (1990). Preventing HIV transmission in health care workers with safer needle devices. Sixth International Conference on AIDS. June 22, 1990: San Francisco, CA.