Sharps Disposal SOP Template

1.Purpose

To prevent needlestick and sharps injuries by making sure sharps are handled safely, disposed of immediately in approved containers, and that injuries are reported and followed up without delay.

2.Scope

Applies to any staff member who uses, handles or disposes of needles, scalpels, lancets or other sharps in clinical areas. Laboratory sharps handling is covered by a separate SOP.

Definitions

Sharps container

A puncture-resistant, labeled container approved for the collection of used needles and other sharps.

Safety-engineered device

A needle or sharp with a built-in feature, such as a retractable or shielded needle, designed to reduce the risk of an accidental puncture.

Needlestick injury

An accidental puncture of the skin by a used needle or other sharp, which requires immediate first aid and reporting.

3.Responsibilities

Clinical Staff Member

Uses safety-engineered devices, disposes of sharps immediately after use, and reports any needlestick injury right away.

Charge Nurse

Monitors container fill levels on the unit, coordinates urgent care for a needlestick injury and reviews incident trends.

Environmental Services Technician

Replaces full sharps containers and manages sealed containers through proper biohazard waste channels.

Occupational Health Coordinator

Manages the needlestick injury response, testing and follow-up care.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Wall-mounted or portable sharps containers at point of use
• →Safety-engineered needles and sharps devices
• →Needlestick injury report form
• →First aid supplies (soap, running water, antiseptic wipes)
• →Biohazard waste pickup log

Personal protective equipment

• →Disposable gloves

5.Procedure

1. 5.1

   Select a safety-engineered device

   Clinical Staff Member

   Use the safety-engineered needle or sharp provided for the task whenever one is available, and confirm the safety mechanism is functioning before use.

2. 5.2

   Position a sharps container within reach

   Clinical Staff Member

   Before starting a procedure involving a sharp, confirm a sharps container is within arm's reach so the used sharp does not need to be carried across the room.

   Checkpoint: A sharps container is positioned within reach before the procedure begins, not after.

3. 5.3

   Activate the safety mechanism immediately

   Clinical Staff Member

   Activate the retractable or shielded safety feature immediately after use and before setting the device down.

   Warning: Never leave a used, unshielded sharp on a tray, bed or counter, even for a moment.

4. 5.4

   Dispose of the sharp directly into the container

   Clinical Staff Member

   Drop the used sharp directly into the sharps container yourself; never pass a used sharp to another person or leave it for someone else to dispose of.

   Warning: Never recap a used needle by hand. Use a one-handed technique only if recapping is unavoidable and required by the device.

5. 5.5

   Check the container fill level

   Clinical Staff Member

   Check the fill line on the sharps container before and after use, and never force additional sharps into a container filled past the line marked on the container.

   Checkpoint: No sharps container on the unit is filled past its marked fill line.

6. 5.6

   Replace a full container

   Environmental Services Technician

   When a container reaches the fill line, close and seal it, replace it with a new container mounted at the same location, and label the sealed container with the date.

7. 5.7

   Transport sealed containers safely

   Environmental Services Technician

   Move sealed sharps containers to the designated biohazard waste storage area using a cart or bin that prevents tipping or puncture, and log the pickup.

8. 5.8

   Provide immediate first aid after a needlestick

   Clinical Staff Member

   If a needlestick or sharps injury occurs, wash the area immediately with soap and running water, or flush mucous membranes with water, without squeezing or scrubbing the wound.

9. 5.9

   Report the injury immediately

   Clinical Staff Member

   Report the needlestick injury to your charge nurse and occupational health immediately, without waiting until the end of the shift.

   Warning: Delaying a needlestick report can delay time-sensitive follow-up care. Report it right away.

10. 5.10

    Coordinate urgent evaluation

    Occupational Health Coordinator

    Arrange for the injured staff member to be evaluated promptly according to the facility's occupational health protocol, including source patient testing where applicable.

11. 5.11

    Complete the incident report

    Charge Nurse

    Document the circumstances of the injury, including the device involved and whether a safety mechanism was used, on the needlestick injury report form.

12. 5.12

    Review trends and retrain

    Occupational Health Coordinator

    Review needlestick injury reports for patterns by device, unit or task, and schedule retraining or a device change if a pattern is identified.

6.Quality checks

• →No sharps container on any unit is filled past its marked fill line.
• →Safety-engineered devices are used for eligible procedures across audited units.
• →Every needlestick injury is reported and evaluated within the facility's required timeframe.
• →Sharps containers are positioned within reach at every point-of-care location.

7.Records

• →Needlestick and sharps injury reports
• →Occupational health evaluation and follow-up notes
• →Sharps container replacement and pickup log
• →Device and unit trend review notes

8.KPIs

• →Needlestick injury rate per staff or per procedures performed
• →Percentage of injuries reported within the required timeframe
• →Sharps container overfill rate found during audits
• →Percentage of eligible procedures using safety-engineered devices

9.Common mistakes

• →Recapping a used needle by hand instead of using a one-handed technique or not recapping at all.
• →Carrying a used sharp across the room to find a container.
• →Forcing extra sharps into a container that is already past the fill line.
• →Waiting until the end of the shift to report a needlestick injury.

10.Revision history