Bloodborne Exposure Incident Report Form (Page 5 of 8) in pdf

Bloodborne Exposure Incident Report Form Page 5

Institution _______

ID _______

23. Circumstances contributing to this exposure:

(Choose all that apply. Rank in order of importance [1=most important].)

A.__ Unfamiliar Procedure

B.__ Concern about patient’s infection/illness

C.__ Difficulty with procedure

D.__ Rushing Procedure

E.__ Pressure from environment

F.__ Location of Instruments

G.__ Location of equipment (e.g. handpieces, mobile cart)

H.__ Faulty or malfunctioning equipment

I.__ Being distracted

J.__ Poor visibility

K.__ Poor positioning

L.__ Not following procedure steps correctly

M.__ Other (specify____________________________)

24.

Was the instrument involved in this exposure reused on the patient after the incident without recleaning?

___Yes ___ No ___ Unknown

25.

What might have prevented this exposure?:

A.__ More instruction

B.__ More assistance

C.__ More time

D.__ Less pressure

E.__ Having more experience

F.__ Better personal protective equipment (specify______________________)

G.__ Safer devices (specify______________________)

H.__ Improved engineering controls (specify______________________)

I.__ Better location of instruments

J.__ Better location of equipment

K.__ Better visibility

L.__ Better positioning

M.__ Other (Be as specific as possible)

(specify ___________________________________________________)

EXPOSURE REPORT TEMPLATE

May 2000

Bloodborne Exposure Incident Report Form Page 5