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WST-SOP-001: Sharps and Clinical Waste Management

Organisation name
Site or unit
Standard operating procedure
Sharps and Clinical Waste Management
Document ID WST-SOP-001-EN Version 1.2
Status To be issued Issue date  
Review date   Replaces 1.0
Owner Clinical lead for this procedure Approved by  
Classification Internal Applies to All clinical areas
Signature  

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

Contents

1. Purpose 2
2. Scope 2
3. Definitions 2
4. Background 2
5. Responsibilities 3
6. Materials and equipment 3
7. Safety and exceptions 3
8. Procedure 3
9. Worked examples 4
10. Decision points 6
11. Escalation 6
12. Monitoring and compliance 6
13. Records 6
14. Training and competence 7
15. Related documents 7
16. References 7
17. Change history 7
Abbreviations 1
Annex A. Sharps and waste audit record 7

Abbreviations

Abbreviation Meaning
SOP Standard operating procedure
WHO World Health Organization
WST-FRM-001 Waste collection record (form)

Key points

  • Put sharps straight into a sharps container at the point of use. Never recap, bend or break needles.
  • Close a sharps container when it is two-thirds full, label it with the date and your initials, and move it to the waste store.
  • Segregate each waste item into the category and colour set by the hospital at the point of use.
  • If you are injured by a sharp: wash the wound, report at once, and follow the occupational health procedure.
  • Stop and get help straight away if a container cannot be closed, a collection is missed, or a spill is larger than the spill kit can manage.

Purpose

To protect staff, patients and the public from injury and infection from sharps and clinical waste, and to make sure waste is collected, stored and disposed of lawfully. Sharps injuries and the mishandling of waste are preventable harms: each one follows from a step done at the wrong time, in the wrong container, or in the wrong place. This SOP sets out the steps and the reasons for them. It supports criterion 2B.5.

Scope

Element Coverage
Who All staff who generate, handle, store or move waste at the facility.
Where All clinical areas, laboratories, theatres, dental areas, the waste store and the collection point.
When At the point of use; during storage; at each collection; and during any spill.
Not covered Radioactive waste and pressurised gas cylinders, which have their own procedures.

Definitions

Term Meaning
Sharps Any object that can cut or puncture the skin: needles, scalpels, lancets, glass ampoules, and broken glass contaminated with body fluid.
Clinical waste Waste that is infectious, anatomical, pharmaceutical or otherwise hazardous, classified by the hospital and the national rules.
Segregation Separating each item into its category at the point of use, so that it goes into the right container.
Waste manifest The record, signed by the collector and the hospital, for each collection.
Spill kit The equipment on each unit for cleaning up body fluid and broken glass: gloves, absorbent material, a sharps-safe scoop, and a bag.

Background

The World Health Organization’s handbook Safe management of wastes from health-care activities (2nd edition, 2014) gives guidance on the safe handling and disposal of health-care waste in normal situations and emergencies, including the hazards of contaminated needles [1]. This SOP applies that guidance together with the hospital’s colour and category rules, which must match the national rules for clinical waste.

Responsibilities

Role Responsibility
Clinical director Approves this SOP and receives the quarterly waste audit.
Facilities or waste manager Arranges collections, maintains the waste store, and keeps the manifests.
Unit manager Ensures containers and bins are stocked, in date and labelled, and that the spill kit is complete.
All staff Dispose of sharps and waste at the point of use, in the correct container, and report any injury at once.
Occupational health Manages the response to any sharps injury.

Materials and equipment

Item Requirement
Sharps containers Puncture-resistant, with a fill line, a closing lid, and a label area. Placed at the point of use, at arm’s reach.
Clinical waste bins Colour-coded by category, as set by the hospital, with the category printed on the lid.
Spill kit On each unit and in the waste store, checked each shift and restocked after use.
Collection record WST-FRM-001 The current form for each collection.

Safety and exceptions

  • Never reach into a sharps container and never force a full container closed.
  • Broken glass contaminated with body fluid is handled as a sharp, using tongs or a brush and pan with a sharps-safe scoop. It is never picked up by hand.
  • Single-use only. A sharp is used once, then discarded. Do not pass a used sharp to another person, and do not leave one unattended on a trolley.
  • Injury. Wash the wound with soap and running water (do not scrub or squeeze it), report at once to the clinician in charge, and attend occupational health the same day.

Procedure

Before you start

  • Check that a sharps container of the right size is at the point of use, and that the bins are labelled with their categories.
  • Check that the spill kit is complete and in date.

Step 1. Dispose of sharps at the point of use

  1. Dispose of the sharp immediately after use, into the sharps container at arm’s reach. Do not put it down on the bed, the trolley or the floor first.
  2. Do not recap the needle. Do not bend or break it. Use a safety device where the facility has provided one, and activate it as the manufacturer directs.
  3. Do not overfill the container. When it reaches the two-thirds line, close it.

Step 2. Segregate other waste

  1. Decide the category of each waste item before you put it in a bin. Use the category set by the hospital for infectious, pathological, pharmaceutical, cytotoxic and general waste, which must match the national rules [1].
  2. Put each item in the bin for its category and colour. Do not place a different category in the same bin.
  3. Close and replace each bin at the fill point set by the unit’s waste plan, and at the end of the shift.

Step 3. Label and store

  1. Label each closed sharps container with the date, your initials, and the unit.
  2. Take closed containers to the waste store. Keep the store locked, labelled, clean and dry.
  3. Do not store waste in a corridor, an exit, or a clean utility room.

Step 4. Collect and record

  1. At each collection, complete WST-FRM-001 with the date, the number and type of containers, and the unit.
  2. Obtain the collector’s signature on the waste manifest. Keep a copy in the waste store file.

Step 5. Respond to a spill

  1. Clear the area and keep others away. Put on gloves and apron.
  2. Cover body fluid with absorbent material. Pick up broken glass with the sharps-safe scoop, never by hand.
  3. Place all material in the correct container, and clean the area with the approved disinfectant. Record the spill and report it to the unit manager.

Worked examples

Situation What to do
A nurse has drawn up a dose and the needle is still on the syringe, and the container is across the room. Do not carry an uncapped needle across the room. Ask a colleague to bring a container to you, or go to the nearest one, and dispose of the sharp directly into it without recapping. Report to the unit manager that no container is at the point of use.
A sharps container reads “two-thirds full” when a new patient needs a cannula. Close the container now, label it, and take it to the store. Replace it with an empty container at the point of use before the procedure.
A health-care worker is cut by a used scalpel blade during cleaning. Wash the wound with soap and running water, do not squeeze it, report to the clinician in charge at once, and attend occupational health the same day. Record the injury.
The waste collection is missed, and the store is full. Keep the store locked, do not leave containers in corridors, and escalate to the facilities manager the same shift. Record the missed collection and the actions taken.
Container AKeep in useContainer BClose and labelContainer CFull: replaceTwo-thirds full: close and label

Figure 1. Sharps container fill levels

Sharp or waste item ready for disposalDispose at the point of use, immediately, without recappingContainer at two-thirds full?YES: close, label with the date and initials, move to thewaste storeNO: continue; do not overfillOther waste: choose the category bin at the point of useStore locked; record the collection on WST-FRM-001; collectorsigns the manifestSpill or injury: follow Step 5 and the injury procedure

Figure 2. From point of use to collection

Decision points

If Then
Container two-thirds full Close, label, and move to the store.
Container cannot be closed Stop using it; do not force it; call the facilities manager for a replacement.
Collection missed Escalate to the facilities manager; keep the store locked and secure.
Spill larger than the kit can manage Clear the area, isolate it, and call for help.
Sharps injury Wash, report at once, and attend occupational health the same day.

Escalation

Event Inform Timescale
Sharps injury Clinician in charge and occupational health Immediately; attend the same day
Missed collection or overfilled store Facilities manager and unit manager Same shift
Repeated container or segregation failures on one unit Unit manager and quality team Within one week

Monitoring and compliance

Indicator Target Method Frequency Owner
Containers closed and labelled at two-thirds full 100% of sampled containers Inspection of 20 containers per unit Monthly Unit manager
Segregation correct at point of use 100% of sampled bins Bin inspection, 20 per unit Monthly Unit manager
Collections recorded on WST-FRM-001 100% of collections Review of manifests Monthly Facilities manager
Sharps injuries Reported at once and reviewed Incident data Quarterly Occupational health

Records

Record Kept in Retention
WST-FRM-001 collection record and waste manifest Waste store file As set by the institutional retention policy
Sharps injury reports Occupational health file As set by the institutional retention policy
Spill records Unit file As set by the institutional retention policy

Training and competence

  • Induction: sharps handling, the point-of-use rule, colour segregation, the store, the spill kit and the injury procedure, with a supervised practical session.
  • Annual update: segregation and spill response, with a check of the bins and the spill kit on the unit.

Related documents

ID Title Relationship
IPC-POL-001 Infection prevention and control programme Sets the wider programme
ID-SOP-001-EN Patient Identification and Specimen Labelling Specimen waste and labelling

References

  1. World Health Organization. Safe management of wastes from health-care activities, 2nd edition. Geneva: WHO; 2014. Source read: the PAHO record of the handbook. The handbook’s specific categories and colour codes must be checked against the full text before publication. Available from: https://www.paho.org/en/documents/safe-management-wastes-health-care-activities-2nd-ed

Change history

Version Date Summary of change Approved by
1.0   First approved version. ASF Expert Committee
1.2   Substantive revision: point-of-use steps, segregation, store and spill procedure, injury response, worked examples and fill-level chart; references checked.  

Annex A. Sharps and waste audit record

Use this record for each audit session. Record one line per container checked. Enter Y, N or NA as shown in the column heading.

Date Unit Container closed and labelled (Y / N) Closed at two-thirds full (Y / N) Segregated correctly (Y / N) Collection recorded (Y / N / NA) Injury reported (Y / N / NA) Comment
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