InTouch CLINICAL UPDATE

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1 InTouch CLINICAL UPDATE 수술실내안전 환자안전과감염예방에관심이있는간호사의평생교육을위한자기학습연구서 ISSUE 2 핵심주제 수술실의료종사자의안전을위한중요요소수술실의료종사자의사고사례연구예방방법법제화필요성 안전장치구현 현명한투자 조직의의료종사자안전챔피언되기 의료종사자의안전이환자에게미치는영향참고문헌 학습목표 참가자들을위한본학습의목적은다음과같습니다 : 1. 수술실 (OR) 에서의료종사자의안전의중요성과복잡성을이해한다. 2. 특히자상사고와신체부상등 OR 의료진의안전을저해하는예방가능한주된사건의특징을설명한다. 3. 업무상상해를줄이는데필요한행동을살펴본다. 4. 변화에대한비즈니스사례를작성하고진료과챔피언을참여시키는등의전략을요약설명한다. 5. 수술환자의안전과 OR 의료진의안전의중요한관계를인식한다. Cathryn Murphy PhD, CIC 골드코스트본드대학교보건의과학명예겸임부교수 교수는전세계하고있고저자입니다 총괄호주퀸즈랜드 에컨설팅을제공 의본발행본 교수는년부터년월사임하기까지호주보건의료안전품질위원회 의보건의료관련감염 자문위원회에초빙전문위원을역임했습니다 본발행본에의견은저자로써의의견이고이나본드대학교의공식입장을대변하지않습니다

2 수술실의료종사자의안전중요요소 수술실 (OR) 은업무상상해를입기매우위험한환경으로인식되어있습니다. 대개이러한환경에서발생하는업무상상해는사고에의한피부손상, 낙상, 미끄러지거나걸려넘어지는경우또는과도한힘이나무거운것을들거나과신전또는오랜시간정적자세를유지하여생기는근골격계의스트레스가원인입니다. 1 OR 설계, 선이있는전기장치와같은장비들, 무균상태를유지하는데필요한움직임과공간적제약, 환자가무의식상태라스스로이동하거나자세를바꿀수없는경우, 날카로운물품 (sharps) 와같은수술기기및기구의중량과디자인과같은수술환경의고유한특징은 OR 간호사의부상위험을높입니다. 1 위험이높은환경다른임상환경에비해수술실에서날카로운물품을사용하는경우가많다. 날카로운물품을자주건네고다루고폐기하면서 OR 의료진들이자상사고를입게됩니다. 자상사고가발생하면 B와 C형간염및 / 또는인체면역결핍바이러스 (HIV) 와같이심각한혈액매개바이러스성병원균에노출될수있습니다. 특히 OR 간호사들에게발생하는자상사고률을검토한한호주연구에따르면, 손상률은수술 1,000회당 건입니다. 2 최근의해외연구자료인 1993년부터 2006년까지미국의 87개병원에서수집한자료에따르면, 보고된전체업무상자상사고의 3분의 1 가량이수술실에서발생한것이고, 이중 4분의 3이의료종사자들은수술팀원들사이에날카로운물건을전달하며입은것입니다. 3 보고된전체업무상자상사고의분의가량이수술실에서발생한것이고이중분의이의료종사자들은수술팀원들사이에날카로운물건을전달하며입은것이다 인체공학과관련된상해와자상사고와같이 OR 간호사가입는업무상부상에대한신뢰할수있는자료는아직보고되지않았습니다. 광범위한검색에도이와같은연구에대한자료는없었습니다. 세계최대수술실간호사협회인미국수술간호사협회 (AORN, Association of Perioperative Registered Nurses) 는수술전후담당의료진과환자에게안전한의료환경을제공하는것을중요하게고려하고있습니다. AORN은내원및외래환경을위한 수술전후표준및실무권장지침 (Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings) 최신판에명시된일련의 안전한의료환경을위한실무권장지침 (Recommended Practices for a Safe Environment of Care) 을통해이문제를다루고있습니다. 1 AORN은수술전후환경에날카로운물품에의한손상방지에관한지침도따로발표했습니다. 4 각문서에는안전에관한실무권장사항과작업조건에관한자세한지침이명시되어있습니다. 또한이권장사항준수와관련해경영진과의료종사자각각의역할을분명하게언급하고있습니다. 호주에 AORN와같은기관인호주수술간호사협회 (ACORN, Australian College of Operating Room Nurses) 는아직 OR에서발생하는업무상상해해결을위한구체적인지침이나실무기준을발표하지않았습니다. 2

3 수술실의료종사자의안전중요요소 전세계전문가들이 OR 간호사들을위한안전한업무환경을제공하려면위험평가와다양한방법의위험감소전략이필요하다는데의견을같이하고있습니다. 보통알려진위험감소전략은다음의행정적전략, 기술적전략또는행동전략중하나에해당됩니다. 5 행정적전략은다음과같습니다 우수한관리구조를수립합니다. 위험감소전략에대해고위경영진이지원과적절한자원을제공합니다. 명확하게작성된승인된정책을직원에게제공하고권장된안전실무가수행되고의료종사자들이이를준수하는지모니터합니다. 충분한의료진들이필요한양의업무를합리적인시간내에안전하게수행하도록합니다. OR 의료진을교육해필요한모든안전조치, 장비및실무를숙지할뿐아니라필요한업무에충분한자신감을지니도록합니다. 사용목적에맞게설계및제작된장비를올바르게사용하면구체적으로목표한위험을없애는등의기술적전략은다음과같습니다 사용자는자상사고의위험을낮추는덮개 (sheathing), 리트랙팅 (retracting) 또는날이무딘 (blunting) 장치등으로날카로운물품 장치에안전조치를합니다. 피로방지매트나의자로장시간서있거나수술팀원들사이에높이차이로인한근골격계압박이나손상위험을줄입니다. 흡수성패드와눈에띄는코드커버로미끄러짐, 발걸림, 낙상등의위험을줄입니다. 리프팅보조기구와장치로환자의체중을재분배하여환자이동과자세변경을용이하게하고의료종사자들의허리부상의위험을 낮추면서마찰과부하및저항을줄입니다 행동적전략은의료종사자들이실무권장사항을준수하도록하는데사용됩니다그범위는대개광범위하고다양하고혁신적이며내용은다음과같습니다 수술실과더광범위한의료환경에서안전하게작업할수있는방법에대해의료종사자들을교육하고인식시킵니다. 의료종사자의행동을모니터, 분석, 보고및교정또는인정해주는시스템을구축한다. 의료종사자들이치료와제공된모든보조기구와안전장비사용에능숙하도록합니다. 의료종사자들이 OR 위험에관한의견을내도록하고해결책을파악, 수행, 평가하는과정에참여시킵니다. 어떤전략을채택하는가는단지중요한요소중하나입니다. 어려운점은조직전반에걸쳐모든직원들이이를수행하도록하는것입니다. 5 병원과수술실에서신체와날카로운물품의안전성을개선하지못하면환자와환자의가족및조직과보건의료시스템에불필요한부담을초래합니다. 다음섹션에서는예방할수있었던 OR 간호사들의심각한부상사례를살펴봄으로의료종사자의안전에대한중요성에대해알아보겠습니다. 3, 5 3

4 수술실의료종사자의부상사례연구예방방법 지난몇년간 Infection Control Plus 직원들은동남아시아와호주의수술협회에몇몇핵심오피니언리더들 (KOL) 을만나, 수술실에서의료종사자안전의현황에대해논의했습니다. 당연히많은 KOL들이업무량증가와업무일정연장및현재수술실의빠른업무속도와관련된우려를나타냈습니다. 보건의료환경이계속변화하면서의료종사자와 OR 의료진의안전을위협할수있는완전히새로운과제가떠오르고있습니다. 구체적으로, 피로감, 요령을피워쉽게하려는경향, 신기술에대한생소함, 수술팀원들의안전에대한무관심은 OR 의료진들의부상위험을높인다고생각했습니다. 그리고이러한요인으로인한의료진부상사례를몇가지예로들었습니다. 가장놀라운이야기중하나는몇년전 HIV 양성환자시술중오염된봉합바늘로날카로운물품에의한손상을입은후업무상 HIV에감염된한 OR 시니어간호사이야기입니다. 다행히초기관리후지속적인의료및약물치료로상태가악화되지않았습니다. 때문에이시니어간호사는노출되기쉬운시술에는배제되었고, 업무부서가 OR에서회복실로재배치되었습니다. 대부분의동료들은아직이간호사의상태를알지못하고, 현재이간호사는안전설계가된날카로운물품의보편적사용을포함한더나은자상사고예방을위한적극적인조력자이자개선을위해적극노력하고있습니다. 이사례를자세히보면어떤측면에서자상사고를예방할수있는지알수있습니다. 이부상은날카로운물품을건네줄때발생했고이는의료종사자들과특히 OR 간호사들에게발생할수있는가장위험한부상중하나라는것도잘알려져있습니다. 3 안전설계가된장치를일상적으로사용하고간호사가 HIV에감염된원인이되기도한날카로운물품전달을위한 중립구역 을엄격히지정하는등사전에사고발생위험을차단해야합니다. 수술시야 (operating field) 에서는날카로운물품을보기쉽지않아위험이높습니다. 수술팀원들의안전에대한무관심은의료진들의부상위험을높인다 4

5 법제화필요성 이사건이발생한지몇년이지난이제의료종사자들은자상사고가발생하는방법, 이유, 시기뿐아니라그예방법에대해서도더자세히알게되었습니다. 그러나날카로운물품이진료시사용되면언제라도자상사고의위험이발생할수있습니다. 6 다행히이러한위험을없애기위한몇가지혁신적안전장치가개발되었고일부국가들은이러한안전장치사용을의무화했습니다. 미국의경우, 의료현장에서부주의로인한자상사고에의해혈액매개병원균에노출되는사고가계속되어심각한문제로대두되자, 2000년에노동안전위생국 (OSHA) 의혈액매개병원균표준 (Bloodborne Pathogens Standards) 에주사침상해방지법 (Needlestick Safety and Prevention Act) 을추가했습니다. 이법에서는자상사고발생시기록하는일지 (log) 를유지하고장치의평가및선택시비경영진의료종사자들의참여시키는추가요건을의무화했습니다. 2010년유럽연합 (EU) 은자상사고를예방해의료종사자들에게가능한가장안전한작업환경을제공하기위해새로운지침 (Directive) 을채택했습니다. 이지침이 2013년공식적으로법제화되면서의료기관들은자상사고로부터의료종사자들을보호하는안전조치를갖추어야합니다. 유럽과북미국가와는달리그이외의국가들은안전설계가 2, 7-15 된장치사용을의무화하는법을갖추지못했습니다. 이러한의료종사자와특히간호사의안전에대한무관심은점점더감염예방과노사관계단체와공개토론회및매체에서논쟁의주제가되고있습니다. 16 안전장치가된날카로운물품사용에대해법적으로강제하고있지않지만, 새로운호주품질안전기준 (Australian Safety and Quality Standards) 의 3.1조에서감염최소화의예로혈액과체액에업무상노출방지에관해명시하고있습니다. 그결과, 호주의많은병원들이자발적으로안전장치의사용을위험관리전략으로채택하고있습니다. 날카로운물품을안전하게건네기위해다양한크기와모양의날카로운물품을담을수있으며눈에쉽게띄는형태의소형 트레이를사용했다면, 앞서말한간호사가부상을피했을것이고이로인해현재생명을위협할수있는질병에걸리지않았을것입니다. 안전장치를제공하고올바르게사용하도록하는것외에도, 본인과동료들의안전을위해 OR 의료진들이취할수있는조치는또있습니다. 이러한조치는날카로운물품에의한신체상해예방에적용되고그예는다음과같습니다 직급에상관없이서로안전하지않은행동과조치를묵인하는대신정중하게문제를제기합니다 위험관리및위험감소솔루션책임자에게현장의중요한조언과피드백을전달합니다 날카로운물품손상과혈청변환이 남의일일것이다 라는잘못된믿음과같은오해를바로잡습니다. 개인적으로는권장된의료종사자안전조치에대한자신의지식행동을개선하고준수및지지를위해노력합니다 5

6 안전장치구현 현명한투자 현대의료계의냉엄한현실중하나는대부분의병원에서예산이줄어들고있다는점입니다. 그결과추가적또는새로운자원과기구를조달하려면면밀하게계획된비즈니스사례를작성해야합니다. 이러한비즈니스사례에는조직별자료와조직에직. 간접적절감혜택에대한설명이포함되어야합니다. 그외에안전장치를도입하는데장애가되는요소로는의사들의거부감, 인식과교육의부족, 비용문제등이있습니다. 6 어떤장비가환자나의료종사자의안전이나건강에관련되어있으면, 제조사들은이관련된의료환경에서주목할만한자료를수집해제공하기어렵습니다. 실제로일부안전장치의경우, 연구자들은그혜택이분명하며윤리적으로안전장치의사용과안전성개선의관계를증명하기에적절한연구를설계할수없는경우가있습니다. 이러한문제는안전한대안이있는비교군에할당된의료종사자가우연히더큰위험에처해해를입을수있기때문에발생합니다. 확실하고신뢰할수있는연구증거가없는병원은보통직원들의사례보고를토대로구매를결정합니다. 또는현장의필요와환경에따라안전장치를구매할수있습니다. 모두병원의적절한태도입니다. 각조직에안전장치조달방법이있겠지만, 다음 10단계로비즈니스사례를준비해안전장치구매를결정할것을제안합니다. 도입하고자하는안전장치최종사용자를대표하는일선직원들과논의하고그들의의견을자주경청합니다 제안된신기술과장비로해결하고자하는의료안전성문제에대해연구하고완전히이해합니다이러한유형의부상과관련해어떻게어떤문제가왜언제어디에서발생하는지판단합니다특히그빈도를확인합니다 재정적및인적차원에서조직개인환자에게예방하고자하는부상의문제점정량화합니다 더안전한대안이이행되지않으면어떤위험과문제가있는지규명합니다 안전장치를통해더안전한시스템으로변화하여얻는혜택을강조합니다 직원교육의필요성이나장치를사용할구역의공간재배치와같이안전장치를이행하는데장애물이되는문제점을파악합니다 새로운안전장치를도입할때그대상배치장소사용방법에대해사전에확실히합의해안전장치를사용해발생하는효과와혜택을측정합니다 적절한양을주문해직원들이항상필요할때안전장치를사용할수있도록합니다 안전장치의효과와조직의투자대비수익에대해평가하고보고합니다 장기간투자할지여부를결정합니다 6

7 안전장치구현 현명한투자 의료종사자들의신체상해와날카로운물품에의한손상의위험을줄이기위해안전조치가된장치와장비를도입하면다음과같은혜택이있습니다. 그러나주요의사결정자들이산업안전보건프로그램을도입해얻는전반적인혜택은즉각확인할수없고경우에따라주목할만한데이터로혜택을분명하게정량화하는데최소 2년은걸린다는점을인식하는것이중요합니다. 보통안전조치가된장치를사용하고조직이직원의건강증진을위해투자하는등면밀히계획된안전프로그램을운영하면다음의이점이있습니다. 직원의부상을방지해낭비를줄이고조직의생산성을높입니다. 조직이산업안전보건의무를준수하도록돕습니다. 환자와직원에게더욱안전한환경을구축해만족도를높입니다. 조직이우수한서비스와의료진의실력에대한명성을유지하도록돕습니다. 그러나주요의사결정자들이산업안전보건프로그램을도입해얻는전반적인혜택은즉각확인할수없고경우에따라주목할만한데이터로혜택을분명하게 정량화하는데최소 년은걸린다는점을 인식하는것이중요하다 7

8 조직의의료종사자안전챔피언되기 특수원인에대한병동이나진료과차원의지지자와옹호자들의노력으로환자의예후와안전및서비스품질이상당히개선된예는많습니다. 가장먼저떠오르는모델은두가지가있습니다. 즉, 병동차원에서감염관리책임간호사와손위생챔피언 (champion) 입니다 지정된진료과의의료진이나팀이의료종사자안전을위한현장챔피언 ( 들 ) 역할을하는유사한모델을채택하면큰개선을이끌어낼가능성이있습니다. 22 본섹션에서는 2009년감염관리역학전문가협회 (APIC, Association for Professionals in Infection Control and Epidemiology) 챔피언키트 (Champion s Kit) 모델을토대로챔피언이되는방법과그프로세스를간략하게설명하고있습니다. 23 챔피언이해야할중요한첫단계는 OR 경영진과 OR 외고위임원등병원지도부의지지를이끌어내는것입니다. 각팀은안전개선을위해해당 OR의노력을지지하는것으로보여야합니다. 즉, 뉴스레터에공개적으로발표하고, OR을방문해직원들이본인의안전을보호하도록독려하고, 더욱실질적으로는 OR에적절한자원을제공해충분한인력과자금으로안전한치료를뒷받침할수있도록함으로써지지노력을보여줄수있습니다 다음단계는 OR에서생각이비슷한사람들로소그룹을만들어안전준수를위한아이디어와이행및증진을돕는역할을하도록합니다. 또한비공식신고네트워크역할을하고시간이흐른뒤 OR 의료진의안전문제에관한중요한의견과적용된전략에대한피드백을제공할수있습니다. UNIT CHAMPION 진료과챔피언은안전개선을위한계획을도출및이행하도록돕는데주된역할을합니다. 이계획에서는프로그램의목표를명시하고확실한임무와활동으로분명한방법을제시해야합니다. 진료과챔피언들의가장어려운임무중하나는동료 OR 의료진들이보이는변화에대한거부감을어떻게해결하는가입니다. 어떤이들은새로운업무방식과새로운기기도입을주저할수있습니다. 이런경우, 챔피언은프로세스와상위섹션에설명된조직의비즈니스사례에서확인된혜택을토대로합의한입장을흔들리지않고고수해야합니다. 8

9 조직의의료종사자안전챔피언되기 OR 의료진이새로운안전대책에따라변화하지않을수없게만드는것은진료과챔피언의주된역할이고, 극단적인경우물리적으로위험이있는오래된장비나장치를제거하고특히전체적으로안전조치가된장치와장비로새롭게교체할수있습니다. OR 의료진의안전에즉각적, 심각한또는생명을위협하는위험이없는한, 인증평가나계절성질환발병과같은다른이벤트가없으면의료종사자안전개선집중프로그램을도입하는것이최선일수있습니다. 이프로그램으로의료진을참여시키고새롭고더안전한업무방법으로최대한협력할수있도록하며스트레스와거부감을낮추게됩니다. 수술실에날카로운물품안전독려방법에대해논할때, Kundson의연구에서는 OR 의료진들이하나의수술팀으로써팀원들의수술기법과도구를사용하므로 위험을공유 한다하더라도, 본인의안전과환자의안전에대해개인적으로책임져야한다고강조했습니다. 22 그외에챔피언의주된임무와변화를이끄는확실한방법은아래박스안에내용과같습니다. 23 이방법이적절히적용되면수술실내의료진의안전을크게향상시켜수술환자의예후도더좋아질수있을것입니다. 마지막섹션에서는의료종사자들이안전한환경에서근무하게되면환자들은어떤혜택을얻게되는지간략하게설명하겠습니다. 변화를이끄는주된임무와방법 필요한자원을이용할수있도록합니다 핵심메시지를분명하고간단하게전달합니다 의지와열정을나눕니다 영향력있는동료들과협력합니다 성공을인정하고축하합니다 9

10 의료종사자의안전이환자에게미치는영향 수술실에서환자를안전하게다루기위한신체안전지침의중요성에대한최근논의중, Waters의연구에서는 OR 의료진에미치는몇가지긍정적효과를강조했고각의료진이수술환자에영향을미친다고밝혔습니다. 6 이러한혜택은일반의료진의안전프로그램수행결과와비슷합니다.. 첫째, 안전한업무시스템을갖추고안전장비를사용하여근골격계부상위험을줄여야하고, 이를통해업무시간낭비와신체적장애위험을줄이고고숙련된우수한 OR 의료진들이이분야에서오랫동안활동할수있도록합니다. 또한, OR 환경이더욱안전하고편안해지면, OR 의료진들의피로감과스트레스가줄어정상적수준의활동을하고일관되고적정수준의의료서비스를제공할수있게됩니다. 반대로의료과실의주된원인으로알려진피로와스트레스가쌓이면환자에게대단히심각한영향을주게됩니다. 의료과실의주된원인으로알려진피로와스트레스가쌓이면환자에게대단히심각한영향을주게된다 환자의안전과의료종사자의안전에관계는, 환자안전과작업장안전은 전략적으로연계 시켜수술환자와 OR 의료진이기대하는수술예후를모두얻을수있도록해야한다는생각을널리인식시키기위해노력하는 AORN이가장잘설명하고있습니다. OR 간호사들이더욱안전해진다는것은환자가더안전해지고수술예후도더좋아진다는의미합니다. 의료계에서이렇게환자와의료진모두에게유리한개선방법은거의없습니다. 따라서 OR 의료진안전에대해널리검토해보기를권장합니다. 어떤부분에서안전을더욱개선시킬수있는지찾아보고본 InTouch에솔루션을제시해주시면감사하겠습니다. 10

11 References 1. Association of Operating Room Nurses. AORN Guidance Statement: Recommended Practices for A Safe Environment of Care. Denver: Association of Operating Room Nurses,; Hunt J, Murphy C. Measurement of nursing staff occupational exposures in the operating suite following introduction of a prevention programme. Healthcare Infection. 2004;9(2): Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. Journal of the American College of Surgeons. Apr 2010;210(4): Association of Operating Room Nurses. AORN Guidance Statement: Sharps Injury Prevention in the Perioperative Setting. Denver: Association of Operating Room Nurses,; Hughes R, ed Patient Safety and Quality: An Evidence- Based Handbook For Nurses. Rockville (MD): Agency for Healthcare Research and Quality; Spratt D, Cowles Jr CE, Berguer R, et al. Workplace Safety Equals Patient Safety. AORN Journal. 2012;96(3): Murphy C. Improved surveillance and mandated use of sharps with engineered sharp injury protections: a national call to action. Healthcare Infection. 2008;13(2): Alliance for Sharps Safety and Needlestick Prevention in Healthcare. Preventing needlestick injuries in the healthcare workplace. 2009; consensus-statement/. Accessed 19/11/2012, Australian Safety and Compensation Council. Occupational Exposures in Australian Nurses. Canberra: Australian Government; Slater K, Whitby M, McLaws ML. Prevention of needlestick injuries: the need for strategic marketing to address health care worker misperceptions. Am J Infect Control. Oct 2007;35(8): Tseng D, Sinnott M, Collier J, Wall D, Whitby M. Prevention of scalpel blade injuries: Staff ignorance of the Australian/ New Zealand Standard. Healthcare Infection. 2005;10(3): Whitby M. Guest editorial: Needlestick injuries (NSIs): an ongoing problem. Healthcare Infection. 2004;9(2): Whitby M, McLaws ML, Slater K. Needlestick injuries in a major teaching hospital: the worthwhile effect of hospitalwide replacement of conventional hollow-bore needles. Am J Infect Control. Apr 2008;36(3): Jagger JC. Are Australia s healthcare workers stuck with inadequate needle protection? The most direct way to reduce percutaneous injuries is to make devices safer. Med J Aust. Oct ;177(8): Whitby RM, McLaws ML. Hollow-bore needlestick injuries in a tertiary teaching hospital: epidemiology, education and engineering. Med J Aust. Oct ;177(8): Needlestick Injuries Putting Nurses At Risk. 2013; Accessed 30th May Cooper T. Educational theory into practice: development of an infection control link nurse programme. Nurse Educ Pract. Mar 2001;1(1): Rickard NA. Hand hygiene: promoting compliance among nurses and health workers. British journal of nursing. Apr ;13(7): Dawson SJ. The role of the infection control link nurse. The Journal of hospital infection. Aug 2003;54(4): ; quiz Teare EL, Peacock AJ, Dakin H, Bates L, Grant-Casey J. Build your own infection control link nurse: an innovative study day. The Journal of hospital infection. Aug 2001;48(4): Pantle AC, Fitzpatrick KR, McLaws ML, Hughes CF. A statewide approach to systematising hand hygiene behaviour in hospitals: clean hands save lives, part I. The Medical journal of Australia. Oct ;191(8 Suppl):S8-S Knudson L. Championing sharps safety in the OR. AORN Connections. May ;95(5):C5-C APIC. The Champion s Kit: Your Resource For Reducing Infections. 2009; Accessed 29/05/2013, Useful websites and resources 1. Alliance for Sharps Safety and Needlestick Prevention in Healthcare 2. Australian College of Operating Room Nurses (ACORN) 3. Association of Perioperative Registered Nurses (AORN) 4. APIC. The Champion s Kit: Your Resource For Reducing Infections. 2009; 5. European Agency for haelth and safety at Work council-directive eu-prevention-from-sharp-injuries- in-the-hospital-and-healthcare-sector 6. NIOSH/ CDC Safe Patient Handling 7. Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality; March resources/nursing/resources/nurseshdbk/index.html 8. Sharps and Ergonomic Safety in the Healthcare Setting educationalprograms/sharps_safety/page22.cfm 9. United States Department of Labour Occupational Health and Safety Administration 11

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