A recent inspection initiative by the Health and Safety Executive (HSE, 2016) aimed at gauging compliance with regulations seeking to prevent injuries from health care sharps in the NHS has revealed a general failure to properly apply the requirements of the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
Sharps or needlestick incidents are one of the most common causes of injury to staff, including midwives, in health care and they carry a serious risk of harm through the transmission of blood-borne infection (NHS European Office, 2013). Sharp injuries occur when a sharp instrument such as a needle, scalpel or stitch cutter penetrates the skin. If the sharp instrument is contaminated by blood, transmission of infection is possible (NHS European Office, 2013).
Health and safety law
The HSE has long been aware of the risk to health service staff from sharps incidents and has taken action for a breach of health and safety laws following health care sharps injuries. In R v Worcestershire Acute Hospitals NHS Trust [2010] (Unreported, October 8), an NHS Trust pleaded guilty and was fined £12 500 with £9000 costs when a trainee phlebotomist, who was taking blood from an infected patient, unmonitored, caught her wrist on the needle.
General duties on the NHS to ensure the health and safety of staff are set out in the Health and Safety at Work etc Act 1974 and its regulations, but they failed to stem the number of sharps injuries in health care throughout the EU. In the UK alone, there was a near 50% increase in reported sharps injuries between 2002 and 2005, leading to an European-wide agreement on measures to prevent sharps injuries (Council Directive 2010/32/EU).
In the UK, these measures were implemented by the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
Application of the regulations to midwives
The 2013 regulations apply to organisations whose primary activity is to manage and provide health care and including situations where employees provide care for people in their own homes. The regulations apply to midwifery services, and managers must ensure that risk assessments and arrangements to comply with the regulations take account of the circumstances that midwives work in, including arrangements for lone workers.
Duties under the 2013 regulations
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 set out specific requirements that must be taken by a midwife's employers.
The key change in approach in the regulations is on the prevention of unnecessary exposure to sharp instruments. The HSE recognises that midwives will continue to use instruments such as needles, scalpels and stitch cutters, as they are essential tools in practice. However, the regulations require midwifery managers and employers to ensure that sharp instruments are only used where they are necessary. Managers must audit the use of sharps in midwifery practice and identify situations where their use can be excluded. The HSE (2013) cites an example of needles being used to collect urine samples from catheter bags when this is not necessary. Midwifery managers must also introduce needle-free equipment where it is available and reasonably practicable to do so (Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, regulation 5).
Use of safer sharps
Where it is not considered reasonably practicable to avoid the use of sharp instruments in a procedure, the 2013 regulations require the use of safer sharps that incorporate protection mechanisms where it is reasonably practicable to do so. This might include the use of syringes and needles that have a shield to cover the needle after use.
Procedures for the safe use and disposal of sharps
Where safer sharps are not available, safe procedures for working with and disposing of the sharp instrument must be in place. For midwives, this will include a requirement to ensure safe procedures for the use and disposal of sharps that might be used in the woman's own home.
Preventing the recapping of needles
Midwifery managers must ensure that their staff do not recap needles and sharps unless a risk assessment demonstrates that it is required to prevent a risk. Where this is the case then devices such as needle blocks must be provided to control the risk of injury.
Sharps disposal containers
Clearly marked and secure containers must be provided and must now be placed close to where sharps are used, together with written instructions for midwives on how to safely dispose of the sharp. This includes the provision of suitable containers for use in a woman's home. A risk assessment needs to demonstrate that the type of sharp, portable sharp container and information for staff is appropriate for the environment the midwife is working in.
Information and training
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013, regulation 6, places a duty on employers and their managers to work with safety representatives to develop information to be given to staff about the risks from sharps. The regulations require that such information covers:
As well as the provision of information, there is a duty to ensure that midwives are given training on how to work safely with the sharps used by them in practice. The 2013 regulations require that this training covers:
Duty to report sharps injury
Under the 2013 regulations, midwives have a duty to notify their employer of a sharps incident at work no matter how trivial. There must be arrangements for the timely report of such injuries including arrangements for out-of-hours reporting followed by an investigation proportionate to the seriousness of the injury. A clean needle injury will not require as rigorous an investigation as an incident where there is exposure to blood-borne infection.
Findings of the inspection initiative
The main focus of the HSE inspection initiative was to gather evidence to assess compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 (HSE, 2016). Of the 40 organ isations inspected, 34 were in breach of the regulations. These breaches were mainly in relation to the requirement for the safe use and disposal of sharps under regulation 5, information and training under regulation 6, and arrangements in the event of an injury under regulation 7 of the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
Breaches in relation to the use and disposal of medical sharps included:
Conclusion
The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 place duties on midwives and their employers to prevent the risk of exposure to blood-borne infection from injury caused by health care sharps.
From its inspection initiative into compliance with the 2013 regulations, the HSE found widespread breaches and issued improvement notices that legally require organisations to take action to comply with the law.
Midwives must ensure that they are familiar with local policies, procedures and risk assessments relating to their work and that they comply with the safe systems of working with sharps set out by their employer, and must inform the process of ensuring that the equipment, risk assessments, information and training in relation to sharps are suitable for the unique areas in which they practise.