QAP OF NEEDLESTICK INJURY,

(NSI) KKM STAFF

Format:

WEHU A1, A2 – Notification of Occupational injury

OHU/NSI/FORMAT QA1 – Format Penyiasatan Tempat kerja

OHU/NSI/FORMAT QA2 – Soalselidik “needlestick Injury”

di Kalangan Anggota Kesihatan

OHU/NSI/FORMAT QA3 – Format Maklumbalas Dari Negeri

berkaitan Indikator “Incidence Rate
of Needlestick Injury

JKNSWK/K/ OHU/POE/HC W.95/Rev. 2002

MANAGEMENT AND NOTIFICATION OF POST OCCUPATIONAL EXPOSURE TO NEEDLE
STICK INJURY (HYPODERMIC AND SUTURE NEEDLE), “SHARPS”, BLOOD, BLOOD
PRODUCTS AND BODY FLUIDS AMONG HEALTH CARE WORKERS)

SUBMISSION OF REPORT For cases of QAP, NSI :

Submit (Monthly):

1. WEHU A1, A2 ,
2. OHU/NSI/FORMAT QA1 ,
3. OHU/NSI/FORMAT QA2 and
4. JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002

Submit Half Yearly :

1. OHU/NSI/FORMAT QA3
 WEHU – A1 JKKP 6
Kepada :
Ketua Pengarah
Jabatan Keselamatan dan Kesihatan Pekerjaan
Negeri : _____________________

Tuan,
REPORTING OF OCCUPATIONAL ACCIDENT

1 Place of occurrence:

2 Date of Accident : - - 3. Time accident occured : hrs

Name and Address of person injured

4. Name :

5. Address:

6. District : 7. State : 8 Postcode: 9 Sex : ¡ M ¡ F

10. NRIC No. - - Old IC:

11 Date of Birth: - - 12. Ethnic Group : 13. Nationality:

14. Work Permit No :

15. Passport No :
(If not Malaysian)

16 Current Occupation :
(For Official Use)
17 Job description in brief at
the time of accident :

18 No.of days doing the job before accident occured : О Years О Months О days

19 Cause of accident (summary

of event related to accident) :

He/She was taken to ……………………………………………… for treatment, and was / was not admitted to hospital
at………………………………………….. and discharged on ……………………. . He/She has / has not returned to
his /her normal occupation. No alterations or additions, other than those necessitated by rescue work, have been made to
the site of the accident or to the machinery concerned.

Name and Address of Employer

20. Name :

21. Address :

22. District : 23. State : 24.Postcode :

 WEHU – A2

REPORTING OF OCCUPATIONAL ACCIDENT

Date of notification : - -

I. Particulars of Reporting Unit

1. Unit / Department / Ward :

2. Health facility / Hospital :

II. Particulars of Patient

1. Registration No :

2. Date seen/treated/admitted : - -

III. Classification of Accident

(Shade more than one if relevant)

1. Nature of Injury

O Abrasions O Concussions O Drown

O Amputation O Cuts O Laceration
O Asphyxia O Dislocation O Puncture Wounds
O Burns (Heat) O Effect of Electric Current O Sprain & Strains
O Burns (Chemical) O Effect of Radiation O Internal Injuries
O Bruises & Contusions O Fracture O Others

If others please specify :

2. Parts of Body Injured :

Head & Neck Upper Limb Body Lower Limb

O Scalp O Scalp O Back O Hip

O Skull O Upper Arms O Chest O Thigh
O Eyes O Elbow O Abdomen O Legs
O Ears O Forearm O Pelvis O Knee
O Nose O Wrist O Groin O Ankle
O Mouth O Hand O Feet
O Teeth O Palm O Toes
O Face O Fingers
O Neck O Others

If others please specify :

 WEHU – A2(cont’d)

3. Mechanism of Accident :

O Struck against object O Exposure to or contact with harmful

substances/radiation
O Struck by sliding, falling, flying or other moving objects O Exposure to or contact with electric current
O Motor Vehicle accident O Exposure to explosion
O Caught in or between objects O Drowning
O Fall or slip on same level O Crush by moving/sliding objects
O Fall from a height O Needle stick/Needle prick
O Injured while handling, lifting or carrying O Physical assault
O Contact with extreme temperature O Others
If others please specify :

4. Agency of Accident :

O Machines O Floor/Levels
O Lifting equipments O Ladders
O Transport equipment/vehicles O Scaffolds and staging
O Hand tools O Stairs or Steps
O Pressure Vessels O Explosive/inflammable substances
O Furnaces/Ovens/Incinerator or kilns O Surgical instruments (including needles, scalpels etc.)
O Electric equipments O Wooden plank
O Tree branches/Logs O Others
If others please specify :

5. Recommendation for prevention. If any,

c.c.
Reported by : 1. Pengarah Kawalan Penyakit
Jabatan Kesihatan Awam,
Name : Kementerian Kesihatan Malaysia
Tingkat 2, Kompleks Pejabat-Pejabat
Jalan Dungun, Bukit Damansara
(Please send original copy)
Designation : u.p. Unit Kesihatan Pekerjaan
2. Pegawai Kesihatan Daerah

Date : Note All forms are to be sent

Through State Health Director
 OHU/NSI/FormaT QA1
FORMAT PENYIASATAN TEMPAT KERJA

ARAHAN:
Format ini hendaklah diisi semasa lawatan ke tempat kerja yang terlibat dan diisi melalui temubual, semakan rekod,
pemerhatian, dll.
Bah.Tempat Kerja yang Dilawati : No.Tel :

Alamat Tempat Kerja : Nama & Jawatan Pegawai Untuk Dihubungi :

1. GARISPANDUAN STD
1.1 Adakah terdapar garispanduan berkaitan Ada Tiada Ada
‘Universal Precaution’ ? (5%)

1.2 Jika ADA, adakah garispanduan ini dipamirkan

atau mudah diperolehi ? Ya Tidak Ya (5%)

2. LATIHAN
2.1 Adakah latihan / kursus / taklimat berkaitan Ada Tiada Ada
(3%)
‘Universal Precaution’ dijalankan ?
Sekurang-
2.2 Jika ADA, bilakah latihan yang terakhir - - kurang 6
bulan (4%)
dijalankan ? Hari Bulan Tahun

2.3 Jumlah anggota yang telah dilatih : 100%

100%
(Jumlah anggota di seluruh bahagian: ) 100% - 75%
dilatih
74% - 50% (4%)
(Sila semak rekod bagi mendapatkan maklumat ini) < 50%

3. PERALATAN
 Sarung Tangan
Ya (5%)
3.1 Sarung tangan dibekalkan Ya Tidak

3.1.1 Jika YA, adakah mencukupi? Ya Tidak Ya (5%)

 ‘Sharp collectors’ atau peralatan yang setanding

untuk mengumpul jarum sebelum dibuang /
dimusnahkan. Ya (5%)
3.2 ‘Sharp collectors’ dibekalkan Ya Tidak

3.2.1 Jika YA, adakah ia sesuai? Ya Tidak

3.2.2 Jika TIDAK, nyatakan bagaimana jarum di

kumpul sebelum dibuang / dimusnahkan.
 OHU/NSI/FormaT QA1

4. TATACARA KERJA
4.1 Adakah anggota memberi penuh perhatian Ya Tidak Ya (10%)
sebelum, semasa dan sesudah memberi suntikan
mengambil darah pesakit?
4.2 Adakah jarum suntikan digunakan semula Ya Tidak Tidak
setelah digunakan? (5%)

4.3 Adakah jarum dipisahkan dari picagari setelah Ya Tidak Tidak

di-gunakan? (5%)

4.4 Adakah jarum ditutup semula (Recap) setelah Ya Tidak Tidak

di-gunakan? (5%)

4.5 Adakah jarum yang telah digunakan dibuang Ya Tidak

ditempat yang betul?

5. PEMUSNAHAN JARUM
5.1 Bagaimanakah cara jarum-jarum dibawa ke
tempat pemusnahan?
A. ‘Sharp collector’ dimasukkan kedalam A A (10%)
‘clinical waste bag’ dan dihantar ke tempat
pemusnahan.
B. ‘Sharp collector’ dibawa terus ke tempat B
pemusnahan.
C. Lain-lain, nyatakan : C

5.2 Bagaimana jarum suntikan dimusnahkan?

A. Bakar & Tanam A A atau D
B. Tanam sahaja B (10%)
C. Bakar sahaja C
D. ‘Incinerated’ D
E. Lain-lain cara, nyatakan : E

5.2.1 Jika dibakar dan ditanam, adakah

dilakukan dengan memuaskan? Ya Tidak Ya (10%)

(Lawat dan lihat tempat pemusnahan jarum jika

boleh untuk menjawab soalan ini)

JUMLAH : 100%

Lawatan Dibuat Oleh :

Nama : Jawatan :

Nama : Jawatan :

Tarikh Lawatan :
 OHU/NSI/FormaT QA2

SOAL SELIDIK “NEEDLESTICK INJURY”

DI KALANGAN ANGGOTA KESIHATAN

(Soal selidik ini hendaklah diisi sendiri oleh anggota yang tercedera. Semua jawapan adalah rahsia)

1. Biodata :

Nama :
Jantina : Umur :
Bangsa : Jawatan :
Tempat Bertugas :
Alamat tempat bekerja :
Tempoh perkhidmatan : Bulan / Tahun
Pernahkah anda mengalami kecederaan serupa sebelum ini ? Ya Tidak
Huraikan urutan kejadian untuk kecederaan kali ini :

2. Maklumat Mengenai Kursus / Garispanduan :

2.1 Pernahkah anda menghadiri kursus “Universal Infection Control Precautions” (UICP) ?

Ya Tidak

2.2 Bilakah akhir sekali anda menghadiri kursus tersebut?

Tarikh :
Tempat :

2.3 Adakah terdapat garispanduan “Universal Infection Control Precautions” di tempat kerja anda?
Ada Tiada Tidak Tahu
2.4 Dimanakah garispanduan tesebut ditempatkan?

3. Pengetahuan Tentang UICP :

3.1 UICP melibatkan sekresi-sekresi berikut :
(Tandakan betul √ atau salah ╳ )

1 Blood / Darah
2 Semen / Air Mani
3 Vaginal secretion / Lelehan Faraj
4 Feces / Najis
5 Urine / Air Kencing
6 Sputum / Kahak
7 Vomitus / Muntah
8 Sweat / Peluh
9 Nasal Secretion / Lelehan Hidung
10 Tears / Air Mata
11 Saliva / Air Liur
 OHU/NSI/FormaT QA2
3.2 Alat-alat yang tajam seperti jarum hanya boleh digunakan sekali sahaja?

Ya Tidak Tidak Tahu

3.3 Jarum dan picagari (syringe) boleh digunakan semula bila perlu?

Ya Tidak Tidak Tahu

3.4 Maklumat berikut adalah benar mengenai ‘sharp containers’.

(Tandakan dalam kotak yang disediakan bagi maklumat yang betul).

1 Bersifat Leak-proof dan puncture-proof

2 Ada tangkai yang boleh di angkat sebelah tangan
3 Ada penutup yang mudah untuk dibuka atau ditutup
4 Ada tanda hazard kimia di badannya
5 Di tukar dan disita bila kandungannya tepu dan penuh
6 Ia adalah sisa klinikal
7 Beg sisa klinikal digunakan sebelum dilupuskan

3.5 Apakah cara terbaik melupuskan ‘sharp containers’?

1.
2.
3.

3.6 Apakah langkah-langkah bagi mencegah kecederaan tercucuk jarum?

1.
2.
3.

4. Apakah cadangan tuan / puan bagi mengatasi masaalah kecederaan tercucuk jarum di tempat kerja ?

Tarikh :

Tandatangan :
 OHU/NSI/FormaT QA3

Laporan Bulanan : _________________________________

Daripada : ________________________________________

Kepada : Pengarah Kesihatan Negeri Sarawak,

U/P
Penyelaras QA Indicator Incidence Rate of Needle Stick Injury,
Unit Kesihatan Pekerjaan dan Alam Sekitar,
Jabatan Kesihatan Negeri Sarawak,
Kuching.

FORMAT MAKLUMBALAS DARI NEGERI BERKAITAN INDIKATOR “INCIDENCE RATE OF NEEDLE STICK INJURY”

Kadar Insiden Dearah/Hospital dengan Kelemahan yang Langkah Remedial Catatan

Bagi Seluruh “Shortfalls in Quality” dikenalpasti
Negeri Nama Kadar Insiden Telah dilaksanakan Perlu dilaksanakan
Daerah/ (Dari pengisian dan
(Per 100 anggota Hospital (Per 100 anggota penyiasatan QA1 dan
terdedah pada terdedah pada QA2)
jarum) jarum)
CONFIDENTAL JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002

MANAGEMENT AND NOTIFICATION OF POST OCCUPATIONAL EXPOSURE TO NEEDLE STICK

INJURY (HYPODERMIC AND SUTURE NEEDLE), “SHARPS”, BLOOD, BLOOD PRODUCTS AND
BODY FLUIDS AMONG HEALTH CARE WORKERS)

Instruction, Please Note:

1. This form is to be completed by the Infection Control Nurse/Person In-charge or Injured person
immediately following exposure.
2. Section A to F: for low risk exposure and require no PEP treatment, to be submitted upon discharge of
following-up i.e. after 6 months.
3. Section G: To be submitted upon completion of Post-Exposure Prophylaxis (PEP).
(Please write, and circle where relevant).

(A) PERSONAL DATA OF WORKERS

1.0. Name: ______________________________________

2.0. Identification Card No: _______________________

3.0. Date of injury: _________________

4.0. Gender: [ ] Male [ ] Female

5.0. Age: ______ yrs. Date of birth: _______ (date/mth/year)

6.0. Job category:

[ ] Medical Specialist [ ] Medical Officer [ ] House Officer
[ ] Surgeon (Surgery/Neuro/ Eye/Oral Surgeon and others)
[ ] Dentist [ ] Dental Officer [ ] Dental Technician [ ] Dental Surgery Asst.
[ ] Pharmacist [ ] Pharmacy Assistant [ ] Dental Sister [ ] Dental Nurse
[ ] Nursing Matron [ ] Health Matron [ ] Dental Matron
[ ] Nursing Sister [ ] Health Sister [ ] Staff Nurse [ ] Public Health Nurse
[ ] Nurse Assistant [ ] Community Nurse [ ] Midwife
[ ] Health Attendant [ ] Hospital Attendant [ ] Dental Attendant
Trainee: [ ] Nurse [ ] Medical Assistant [ ] Laboratory Technologist [ ] Medical Student
 Others: [ ] Please specify: ___________________________________________________

JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002

7. Section of where the exposed staff works e.g. ward (surgical/medical), operating theatre,
Clinic (specialist clinic, dental clinic, maternal and child health clinic, pharmacy, laboratory etc.
Others: Please specify __________________________________________

8. Number of years working at present job: ______ years _______months

(B) DETAIL OF EXPOSURE/INCIDENT

9.0. Type of exposure

[ ] Needlestick (hypodermic needle)/suture needle
[ ] Splashes (mucous membranes such as eyes, skin surface (intact/cut/abrasion)
[ ] Injury due to surgical instruments including scaple/ razor/lancet/ scissor (pointed edge) etc
[ ] Injury due to sharps including broken slides, test tube, specimen bottle/ bone fragments etc.
[ ] Others: Please specify _________________________________________________

9.1. Description of exposure

Route of exposure Exposure in term of volume
OEHU USE
[ ] Intact skin Small or large {delete one)
EC 1
[ ] Compromised skin Small or large (delete one)
EC 2
integrity
EC 3
[ ] Percutaneous exposure Severe or less severe

10. Type of infectious material:

[ ] Blood
[ ] Blood and blood products
[ ] Other body fluids, please specify: __________________________________
[ ] Others, please specify: ___________________________________________

11. Type of working hours (tick one) and indicate the time when accident occurred:
[ ] Office hours: ______ am/pm [ ] Night shift: ______ pm//am
[ ] Morning shift: _____ am/pm [ ] Call duty: ________ am/pm
[ ] Afternoon shift: _____ pm Others: Please specify: _____________________
12. Briefly describe the sequence of the incident and specify the injured site e.g, in the process of
obtaining blood sample from patient, patient jerked and I got my self pricked at left index finger or
as I attempted to recap needle after used or manipulate before disposal etc
Others: Please indicate clearly: ____________________________________________________
JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002
13. Any pervious exposure: [ ] Yes [ ] No [ ] Don’t Know [ ] Can’t remember
If yes, ___ time (s). Has incident been reported [ ] Yes [ ] No
In your opinion, is this incident caused by your own carelessness, such as recapping, improper
disposal technique or someone else’s carelessness, such as needle left at bed side or underneath
linen sheet. Your comment: ___________________________________________________
____________________________________________________________________________

(C) HIV AND HEPATITIS B STATUS OF THE SOURCE (INDEX PATIENT) For OEHU use
14. Source patient’s particulars: [ ] known [ ] Unknown [ ] HIV SC 1
[ ] HIV SC 2
14.1. Occupation of source patient; [ ] HIV SC 3
[ ] Permanent job (type of job): ______________________________
[ ] Part time if any (type of job): ______________________________
[ ] Unemployed

14.2. Assessing risk factors. Sexual history

i. Sexual orientation (may tick more than one) [ ] Heterosex [ ] Bisex [ ] Homosex
ii. Any sexual contact with: [ ] Sex worker [ ] Multiple sex partners
iii. Any history of intravenous drug use: [ ] Yes [ ] No
If yes, any history of needle/syringe-sharing [ ] Yes [ ] No

14.3. Serostatus of source patient:

(a) HIV: [ ] Positive [ ] Negative [ ] Unknown
If Positive,
[ ] Lower titre exposure (asymptomatic and high CD 4)
[ ] Higher titre exposure (advance AIDS, primary HIV infection or low CD 4 count)
(b) Hepatitis B: [ ] Positive [ ] Negative [ ] Unknown
(D) STATUS OF EXPOSED STAFF AT TIME OF EXPOSURE
15. Serostatus (tick one)
Hepatitis B: [ ] Positive [ ] Negative [ ] Unknown

15.1. Any Hepatitis B immunization received previously: [ ] Yes [ ] No

If yes:
a) When received: _____________ (day/mth/yr)
b) How many doses: _______________
c) Any booster received: [ ] Yes [ ] No [ ] Unknown [ ] Not applicable (Na)
JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002

HIV: [ ] Positive [ ] Negative [ ] Unknown

If HIV positive:
[ ] Lower titre exposure (asymptomatic and high CD 4 count)
[ ] Higher titre exposure (advance AIDS, primary infection or low CD 4 count)

(E) RISK OF HIV TRANSMISSION

[ ] Low Risk (EC1, SC1)
[ ] Medium Risk (EC1, SC2), (EC2, SC1)
[ ] High Risk (EC2, SC2), (EC3, SC1 or SC2)
[ ] Unknown source or Status (Risk of exposure high)

(F) ACTION TAKEN

1. Counseling [ ] Yes [ ] No

2. Sero testing - source [ ] Yes [ ] No

3. Result - Source : HIV [ ] Positive [ ] Negative

Staff: HIV [ ] Positive [ ] Negative
4. Follow-up: [ ] Required [ ] Not Required

Name of person notifying: ____________________________

Designation: _________________________
Signature: __________________________
Reporting center: ____________________
Date: ___________
Remarks, if any: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 JKNSWK/K/ OHU/POE/HCW.95/Rev. 2002

(G) THIS SECTION IS TO BE FILLED BY INFECTION CONTROL NURSE OR

PERSON IN-CHARGE. To be submitted upon completed PEP treatment.

1. Name: ___________________________________

2. Identification Card No: _____________________

3. Date and time incident notified: ___________(day/mth/yr) ___________ am/pm (circle one)

4. PEP (Post-Exposure Prophylaxis) indicated: [ ] Yes [ ] No

PEP Recommended: [ ] Yes [ ] No
If PEP treatment recommended what is the treatment regime and drug used.
[ ] Monotherapy, specified drugs: _____________________________________
[ ] Basic regime (2 NRTI), specify drugs: _______________________________
[ ] Expanded regime (2 NRTI), specify drugs: ___________________________

5. If PEP treatment recommended: [ ] Accepted or [ ] Not accepted by staff

If not accepted please specify reason (s): _____________________________________
_____________________________________________________________________

6. PEP treatment:
[ ] Completed 4 weeks of treatment
[ ] Discontinued treatment when source found to be negative for HIV
[ ] Discontinue treatment due to intolerance, specify: _________________________
__________________________________________________________________
[ ] Discontinue treatment, change of mind half-way.

7. Other treatment, where indicated. Please specify:

_______________________________________________________________________
 _________________________________________________________________________

JK
Blood Date of @ 0 week @ 6 weeks @3 @6 NSWK/
K/ specimen specimen sent months months
HIV
HBs Ag
OHU/POE/HCW.95/Rev. 2002

8. Blood testing and results

A. Name of attending Physician/Medical Officer: _____________________________

Signature: _________________________

B. Name of notifying person: ______________________________________

Designation: ____________________________
Signature: _______________________________
Name of reporting center: ____________________________________

C. General Remarks: _______________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________