On the offense: Workplace safety

By Allison Evans, Assistant Managing Editor, March 1, 2026

Nonfatal occupational injury and illness rates for health care workers are among the highest of any industry. Health care workers face a wide range of hazards on the job including exposure to sharps-related injuries, infectious biological agents, chemicals such as disinfectants and hazardous drugs, lasers, and more.

Health care workforce safety — physical and emotional — is inextricably linked to patient safety and outcomes as well as the success of a practice. Safety concerns and exposures can affect resignation and retirement rates, and the loss of valuable employees — which may then cause a loss of patients and interruptions in business.

Culture of safety

The OSHA Act of 1970 and OSHA Standards and Guidelines protect workers from job hazards. Employers must provide a safe and healthy workplace, training, and necessary personal protective equipment.

According to the National Institute for Occupational Safety and Health (NIOSH), health care facilities need to foster and promote a strong culture of safety that includes a commitment to worker safety, provision of and adequate access to safety and personal protective equipment, and extensive training efforts that utilize protocols requiring specific safety actions.

This includes recognizing and reporting high-risk exposures and activities, developing and implementing prevention and control standards, policies, and strategies with worker input to mitigate and eliminate hazards, and providing sustained resources to address safety concerns. Focusing efforts on a sound and sustained safety culture will lead to and support better outcomes in patient health care and safer working conditions for health care workers.

“I was a residency program director for about 20 years. In that role, I was constantly dealing with issues related to occupational exposures. Some of them are related to infection, while others are related to physical agents we encounter,” said Vincent Falanga, MD, FAAD, FACP, a dermatologist at APDerm Advanced Dermatology of Melrose, Massachusetts, and a professor emeritus of dermatology and biochemistry at the Boston University Chobanian & Avedisian School of Medicine.

“A serious exposure, with a potentially grave outcome, can throw the whole residency program in disarray. That was always one of my constant fears — that a trainee would get stuck with a needle during a procedure or fail to use appropriate eye protection during laser procedures. One has to provide an environment focused on safety for the residents, patients, and staff,” he added.

Needlestick, scalpel injuries

Needlestick and scalpel exposures are the primary problem in terms of general occupational hazards in health care because of the rather immediate consequences and ramifications. These exposures occur commonly in dermatology, said Dr. Falanga, a co-author of a JAAD review on infectious occupational exposures in dermatology (doi: 10.1016/j.jaad.2005.08.015). Up to 800,000 needlestick exposures occur in the U.S. every year, and most likely a lot more because of underreporting, he stated.

Because of the vast number of surgical procedures, skin biopsies, and injections dermatologists perform, the specialty of dermatology is at particularly high risk. “In one survey, more than 60% of dermatology trainees reported at least one needlestick exposure during their years of training. Mohs surgeons are commonly affected, with about 55% having had a needlestick or scalpel cut exposure during the previous year. Moreover, 5% of Mohs surgeons had exposures to HIV and hepatitis viruses,” Dr. Falanga said.

Despite government regulations aiming to decrease the incidence of needlestick exposures through the Needlestick Prevention and Safety Act (NPSA), which was signed into law in 2000, the number of needlestick exposures has not decreased for every specialty.

“Ironically, the NPSA led to a decrease in needlesticks in the nonsurgical setting but not in the surgical setting,” Dr. Falanga remarked. “The reasons are not entirely clear. It’s possible that those who are heavily involved in surgical procedures do not thoroughly follow all the safety guidelines for needle capping, no-touch technique for suture needles, etc. This non-adherence may be due to lack of time, overconfidence, and increasing number of more complex procedures.”

Minimizing risk of needlesticks

In a previous DermWorld article, Oliver Wisco, DO, FAAD, FACMS, director of the Brown Dermatology Cutaneous Oncology Program and the chair of the department’s Quality and Safety Committee, described a study they conducted at Brown that looked at safety mishaps within their department. They found that wrong-site surgery, errors in specimen processing, and injuries to the health care team were the top safety issues. “Out of non-needle stick injuries and needle-stick injuries, the latter was the biggest issue.”

Several approaches and guidelines have been developed to minimize risks and reduce easily preventable errors. “Prime flaws that diminish safety,” Dr. Falanga remarked, “are re-capping the used needle and re-loading the suture needle into the needle-holder with our hands rather than using forceps or a hemostat for that purpose.”

“Of course, it’s faster to use our hands for those basic tasks, but the failure to follow these guidelines inevitably leads to more needlesticks. Interestingly, some of the safety devices, which are very valuable, have been around for years but some clinicians are not thoroughly familiar with them. This unfamiliarity may lead to misuse of safety devices and may in fact increase injury and exposure,” he said.

The physician performing the procedure usually gets stuck or cut while handling sutures and scalpel. Of course, staff personnel are also vulnerable. “Assistants and staff personnel get injured when receiving the contaminated sharps and disposing of them, or when blotting the surgical wound with the needle still in the operative field,” he stated. “For the protection of staff, the surgical wound should never be blotted with gauze with the suture needle still in the field unless the gauze is grasped first with a hemostat or forceps; the alternative is to use cotton applicators to blot the wound.”

The surgical tray is another point at which safety guidelines can prevent many needlestick and/or scalpel injuries. “By the end of procedures, the tray contains several used sharp instruments, often covered with used and bloodied gauze.”

Dr. Falanga suggested having photos of surgical trays for specific procedures to help remain consistent in the arrangements of instruments. “Some clinicians advocate the use of sterile magnets on the surgical tray for immobilizing suture needles. However, this may cause other metal objects to become temporarily magnetized. A more desirable approach might be the use of foam blocks on the tray to isolate the suture needles.”

Dr. Wisco also focuses on the surgical tray as a way to minimize risk of injury. “One way in which to protect health care staff is to ensure the surgical tray is set up in a standardized way so that everybody knows where the needles should live, which includes suture needles, anesthesia needles, and keeping sharps like the surgical blades and skin hooks in a certain area on the tray.”

Communicating with staff is also an important safety protocol, Dr. Wisco added. “If a needle goes down into the field, let people know where it is — and it has to be closed communication: ‘I’ve put the needle here’ and the staff have to respond, ‘I understand the needle is there.’”

Using two sets of gloves has been shown to be effective in reducing the rate of needlesticks by a ratio of five to one and the amount of blood transfer by 95%, Dr. Falanga noted. “Still, this approach has not been routinely used, likely because of the expense and the false perception that manual dexterity is adversely affected.”

Most injuries in surgery occur, much like everything in medicine, in the transition to the next stage, Dr. Wisco said. “In the surgical environment that includes setting up the tray, using the tray, and taking down the tray. You must think about those very specific steps and what mishaps might happen in the process.”

Bloodborne pathogens

Although there are several infections that can be acquired through needlesticks, there are three main ones: HIV, hepatitis B (HBV), and hepatitis C (HCV). There are important differences in the risk of acquiring these infections after a needlestick, Dr. Falanga noted.

“HIV transmission requires more blood transfer than hepatitis viruses and, in fact, a simple needlestick is unlikely to transmit HIV. The often-cited figure is three for every 1,000 occurrences. Transmission rate through mucous membrane exposure is even less, at nine for every 10,000 occurrences.” He emphasized that despite the rarity of HIV transmission with needlesticks, one should not minimize the risk because of the potential life-changing consequences.

Considered to be the major infectious hazard of health care workers, HBV is the most transmissible of the three pathogens, estimated to be 50 to 100 times more infectious than HIV. It is also the pathogen against which an effective vaccine exists and remains protective for up to 15 years. Transmission of hepatitis viruses requires much less blood than HIV, with rates of transmission of 6% to 63% for HBV and 0.5% to 10% for HCV. “Those wide ranges are due to the fact that higher viral loads or deeper needlesticks are important variables,” Dr. Falanga said.

HCV infection rate falls between HBV and HIV; occupational transmission of HCV occurs approximately 10 times less than HBV and 10 times more than HIV. Currently, no approved methods exist for preventing HCV infection after an exposure. However, the transmission of HCV through occupational exposures to blood is not efficient (doi: 10.1016/j.jaad.2005.08.015).

For HIV, the most sensitive test after exposure is the RNA HIV test, also called nucleic acid test (NAT), whereas the antigen/antibody tests may take many days or weeks to become positive, Dr. Falanga remarked. “Testing for p24, a major HIV protein, is usually positive around day 12, but then it may become negative when the antibody response to HIV becomes pronounced after two to three weeks or so.”

When possible, testing the source of the needlestick with the rapid HIV test is ideal, with results often available within the hour. “If the source is not available (or unwilling to be tested) or if the rapid HIV test is positive, then the needlestick receiver is advised to be treated with a prophylactic anti-HIV drug protocol for four weeks, starting no later than 72 hours after exposure. Repeat testing of the needlestick receiver is performed at baseline, six weeks, 12 weeks, and at six months. During that period of time, pregnancy, breastfeeding, and unprotected sex should be avoided for up to six months, as seroconversion may occur late,” he said.

Exposure to other infectious agents

In addition to bloodborne pathogens, exposure to other infectious agents is possible. “Scabies can be transmitted when we are not thinking about it and in the setting of scaly dermatoses. Gloves must be used at all times in that situation,” Dr. Falanga said.

Other infections can be acquired when not wearing protective gloves, Dr. Falanga noted, including impetigo, herpes simplex, chickenpox and shingles (in people who have not had chickenpox before), and HPV from warts.

Although unusual and rare, there are some dermatoses that are infectious. “As we increasingly encounter more patients from other cultures and countries, we must think of leprosy. It’s not as infectious as ancient cultures used to think but certainly the lepromatous phase, including Lucio phenomenon, can cause transmission,” he added.

Heat-based hazards

“Whenever we cauterize or use lasers, we are likely to create airborne particulates and gases that may contain infectious components — bacterial or viral. This is certainly true in the case of verrucae and human papilloma viruses (HPV). Although OSHA does not have specific standards, we are requested to minimize airborne infectious particles that may affect both the operator, staff, and patients who will subsequently be placed in the same exam room,” Dr. Falanga stated.

Use smoke evacuators during cautery and laser procedures, he advised. “Yes, it can be annoying to use these devices, but they can protect us, staff, and patients. When using these devices, the hose nozzle inlet must be within two inches of the surgical site. It’s not just cautery that creates airborne particles. Heat caused by lasers can vaporize tissues and also lead to a surgical plume containing bacteria, viruses, and other infectious particles.”

Make a plan

Studies have shown that compliance with standard precautions increased when workers feel that their institution has a strong commitment to safety. Each office must have an easily identifiable and retrievable document on site that succinctly details the steps to be taken after an exposure. Dr. Falanga recommended that there should be a dedicated, concise file in the clinic with two copies in different locations.

“Designate a person on a rotational basis to handle all the steps for the receiver of the needle stick, who is likely to be too upset and anxious to follow the required screening steps. Wash and irrigate the site of inoculation. Next, try to obtain testing from the patient, and then accompany the receiver to testing sites for blood drawing for HIV, HBV, and HCV,” he added.

Some decisions regarding prophylactic treatment are frequently updated, so each office needs to have both nationally available resources (CDC and OSHA) and local experts (infectious disease) for consultation, Dr. Falanga advised. “Each office must develop its own locally applicable approach to these important issues.”

“Needlesticks initiate a series of events and steps marked by fear, anxiety, and life-changing possibilities. Just like we do for CPR and other important medical emergencies, there should be periodic sessions in each office to evaluate our preparedness for needlestick exposures and other occupational hazards. Lastly, we need to ensure a workplace environment that does not admonish or create fear when these hazardous events take place. A program director, department chair, or practice manager must strike a balance between showing concern and not being overly upset. The individual being affected by the needlestick, for example, must be unafraid of reporting the incident.”

How to establish a safety program

OSHA’s Injury and Illness Prevention Program (I2P2) provides a framework by which employers can develop and maintain an effective workplace safety and health plan, said Faiza Wasif, MPH, the Academy’s associate director of practice management. She outlined the program’s six major safety and health plan elements.

• Practice leadership: A dermatology practice should establish goals for its safety and health program and determine a process for achieving these goals. The practice should designate a safety officer, who will have responsibility for implementing and maintaining program compliance.

• Worker participation: While management has primary responsibility for the safety program, OSHA also requires that management encourage the input of employees throughout the process. Often, clinical staff members are aware of hazards that nonclinical individuals may not see or understand. Those working in exam rooms, treatment areas, or the laboratory will be more attuned to the chemicals used and procedures performed there.

• Hazard identification and assessment: Use OSHA’s Hazard Assessment form to identify, assess, and document hazards in the practice. Inspect the workplace, solicit input from workers, and document all findings. Review documentation of injuries and illnesses experienced in the practice and identify hazards that may have caused them. Give workers an opportunity to report concerns they may have with an open-door policy, assuring them that there will be no discrimination against those who actively participate.

  For example: Are hallways cluttered, floors wet from cleaning, or cords unsecured? OSHA requires appropriate housekeeping, adequate lighting, and clear pathways to avoid slips, trips, and falls. Physicians must maintain clear, dry, uncluttered floors, or use proper signage for wet floors, and secure all cords, Wasif said.

• Hazard prevention and control: Using the information gathered in the previous step, develop a written hazard control plan that details the hazards found and protections that are available against them.

  • Elimination or substitution: Safer substitutions have already been made for some chemicals. For example, formaldehyde, a known carcinogen, was once used as a disinfectant; glutaraldehyde is now used. Toluene can be replaced by Americlear, ProPar Clearant, and other similar compounds.

  • Engineering controls: Formaldehyde and xylene, both known to be hazardous, are used extensively in histology procedures. Hoods are used to protect employees from exposure to chemicals and sharps containers protect employees from needlestick injuries.

  • Administrative controls: Lasers are used in many skin procedures, but they can have harmful effects on employees unless proper precautions are followed. Administrative controls include the appointment of a laser safety officer, developing and following policies and procedures, and documentation.

  • Personal protective equipment (PPE): PPE is the last line of defense; it is a safety net when other controls are not available or effective. PPE such as gloves, gowns, and masks protect employees from bloodborne pathogens when dealing with potentially infectious materials.

If you need help, consider contacting OSHA’s On-Site Consultation Program, which offers free assistance for helping small and mid-sized businesses establish and improve safety programs.

• Education and training: Schedule a safety meeting to inform employees of the hazards to which they may be exposed along with the hazard controls implemented. Train them on the injury and illness prevention program, how they may access the written plan, and their right to receive a free copy. Let them know that management welcomes their input. Train the entire staff to recognize hazards and know how to protect themselves and others. Include how employees can report injuries, illnesses, and concerns. This training must be documented, and the documentation must be retained for a minimum of three years (some state programs require retention for five years). Refresher education and training must be provided at least annually, but periodic reminders during staff meetings or on bulletin boards are also helpful.

• Program evaluation and improvement: About six months after implementing the controls and providing training, repeat the hazard assessment, confirming that all control measures have been implemented and remain effective. Sometimes implementing one control can inadvertently introduce another hazard. Personnel changes and procedure additions or revisions may create new hazards that must be addressed. Repeating the hazard assessment at least every two years will help ensure that the program remains current and effective.

In the absence of a specific OSHA standard for a particular working environment, employers must adhere to the general duty clause to furnish a workplace “free from recognized hazards that are causing or are likely to cause death or serious physical harm.” This functions as a catch-all to encompass potential hazards that have not been specifically addressed in its standards.

Be prepared for OSHA inspections, Wasif advised. OSHA is allowed to conduct inspections without advance notice, and medical offices are frequent stops on these visits. If an inspector identifies violations of standards or significant hazards, OSHA may issue citations and propose penalties.

OSHA violation penalties

* This amount reflects the actual minimum penalty with all penalty reductions which rectifies error in the previous years’ serious minimum penalty posted.

** For a repeated other-than-serious violation that otherwise would have no initial penalty, a GBP penalty of $472 shall be proposed for the first repeated violation, $1,182 for the second repeated violation, and $2,364 for a third repetition.

Source: www.osha.gov/memos/2025-01-07/2025-annual-adjustments-osha-civil-penalties

Additional DermWorld Resources