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Education and training for preventing sharps injuries and splash exposures in healthcare workers

  • Protocol
  • Intervention

Authors

Abstract

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effects of education and training interventions versus no intervention or alternative interventions for preventing sharps injuries and splash exposures in healthcare workers.

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Background

Description of the condition

In healthcare settings, workers are at risk of acquiring infectious diseases through sharps injuries and splash exposures to blood or bodily fluids. The viruses with the most severe consequences include hepatitis B (HBV), hepatitis C (HCV) and the human immunodeficiency virus (HIV) (Pruss-Ustun 2005). Worldwide, healthcare workers (HCWs) experience over 3 million sharps injuries each year (Pruss-Ustun 2005). This leads to about 66,000 HBV infections, 16,000 HCV infections and 1000 cases of HIV annually (Pruss-Ustun 2005). Developing countries experience the highest prevalence of HIV, and because of limited resources for prevention, there is a high rate of needle stick injuries (Enwere 2014). Exposure injuries among healthcare workers are also commonly not monitored in developing countries (Pruss-Ustun 2005).

The risk of potentially experiencing a sharps injury at work and the concern of acquiring an infectious disease as a direct result of this exposure may cause psychological stress for the HCWs. In turn, this stress impacts on both the workers' functioning in their work and personal life (Fisman 2002; Sohn 2006). There is also the financial burden imposed on health centres due to occupational exposure to blood-borne diseases, which includes costs related to blood tests, treatment, outpatient visits and lost working hours (Lavoie 2014). The transmission of occupational blood-borne infectious diseases may also lead to absenteeism, morbidity and even mortality among workers in healthcare settings.

The actual causes of sharps injuries are multifactorial and include elements that could be modified by educational interventions. Such causes include suboptimal use of personal protective equipment, professional inexperience, a lack of training and education on infection control and occupational health principles, improper management of sharps, and subjective perception of risk (Akduman 1999; Ansa 2002; Clarke 2002; Doebbeling 2003; Fisman 2007; Ilhan 2006; Oh 2005; Orji 2002; Roberts 1999; Smith 2006a; Smith 2006b; Wallis 2007).

Description of the intervention

This review focuses on education and training interventions that specifically aim to prevent sharps injuries and splash exposures among workers within healthcare settings. Verbeek 2004 has identified three intervention strategies in occupational health: elimination or management of hazards in the workplace, changes in healthcare workers' skills and behaviour, and the prevention of disease and associated disabilities. In this review, we will focus on the first two intervention strategies.

Educational interventions aim to decrease sharps injuries and splash exposures by increasing HCWs' knowledge, skills or both regarding the correct choice and safe operation of needles, scalpels and other sharp devices necessary in the delivery of healthcare. We define education as the imparting or shared creation of knowledge, and we consider workers' education to be a composite of their knowledge, attitudes and skills (Verbeek 2004). Educational interventions may consist of group-based instruction or other types of information delivery such as videos, leaflets, protocols and guidelines given to people to watch or read in their own time. Educational meetings can be either didactic (e.g. lecture presentations) or interactive (e.g. workshop with role play and case discussions); however, repeated, active educational interventions that promote interactivity have a higher chance of altering the behaviour of HCWs and sustaining such changes (NHMRC 2010). The intervention can be delivered by an Occupational Safety and Health department, hospital infections committee or another educational body.

We define training as the imparting or shared practice of skills. Training interventions vary in mechanisms used in different healthcare settings. Common approaches include self directed learning modules, presentations, education delivered by a visiting expert, inter-professional education, interactive web-based training and seminars.

How the intervention might work

The key to preventing sharps injuries and splash exposures is HCWs' ability to identify risky situations, react accordingly, act in a safe manner, and consistently and correctly handle equipment. Understanding the mechanisms of injury may also help HCWs to spot risky situations. Training refers to planned efforts to facilitate the learning of specific competencies (Noe 2005; Robson 2010). If underpinned by specialised skills and knowledge, these competencies can help to guide changes in HCWs' behaviour (Robson 2010). There are different levels of engagement in training; we will employ the classifications used by Burke 2006 and Robson 2010. Low engagement training employs oral, written or multimedia presentations by an expert and requires no active participation by the worker. Medium engagement training employs a greater degree of worker involvement, such as lectures with a group discussion and quizzes with feedback. Finally, in high engagement training the worker plays an active role in the training activities through face-to-face or virtual settings and hands-on practice opportunities (Burke 2006).

There are several ways of decreasing or removing exposure to blood and bodily fluids, including the removal of hazards at the source (e.g. the abolition of unnecessary injections) or along the care pathway (e.g. by using safety medical devices, instituting safer workplace practices or using personal protective equipment) (Ellenbecker 1996; Roelofs 2003). Education and training may work at either or both levels, depending on the nature of the intervention. The Centers for Disease Control and Prevention (CDC) have also determined that sharps injuries generally occur during a procedure on a patient, after use, and before, during or after the disposal of a sharp instrument (CDC 2008).

Why it is important to do this review

Education and training for prevention of sharps injuries and splash exposures are part of obligatory professional development for healthcare workers in certain countries. Since practices vary and there are also legislative requirements to protect workers' health and safety, it is important to study the effects of education and training to prevent occupational sharps injuries and splash exposures by means of a Cochrane review. Our review is one of a group of Cochrane reviews that address interventions to prevent percutaneous exposure injuries. The other three Cochrane reviews have assessed the effectiveness of blunt needles (Parantainen 2011), safety devices (Lavoie 2014), and gloves (Mischke 2014). Parantainen 2011 found high quality evidence showing that the use of blunt needles appreciably reduced the risk of exposure to blood and bodily fluids for surgeons and their assistants over a range of operations. In Lavoie 2014, there was only very low quality, inconsistent evidence that most safety devices prevented sharps injuries. The risk of blood contamination was greater with devices that had to be actively switched on. On the other hand, Mischke 2014 found moderate quality evidence that double-gloving when compared to single-gloving during surgery reduces perforations and blood stains, indicating a reduction in sharps injuries.

In addition to Cochrane reviews, there are other systematic reviews that have assessed interventions to prevent sharps injuries. The most recent systematic review focused on educational interventions alone or in combination with safety-engineered devices (SEDs) (Tarigan 2015). The review's meta-analysis showed that training decreased the rate of sharps injuries by 34%, while SEDs were responsible for a 49% reduction. However, the combination of training interventions with SEDs led to a 62% drop in the rate of sharps injuries. There was only one randomised controlled trial (RCT) included in the review. We aim to evaluate a broader range of controlled trials of various types of education and training, alone or in combination with other intervention strategies.

Objectives

To assess the effects of education and training interventions versus no intervention or alternative interventions for preventing sharps injuries and splash exposures in healthcare workers.

Methods

Criteria for considering studies for this review

Types of studies

We will include all published and unpublished randomised controlled trials (RCTs), cluster-randomised trials and controlled before-and-after studies. We will include studies irrespective of language of publication, publication status, publication date or the use of blinding.

Types of participants

We will include workers in all healthcare settings, which means paid employees (aged 18 or over) who are professionally involved in healthcare settings and who are at risk of sharps injuries or splash exposures to blood or bodily fluids. Over half of study participants will have to fulfil this criterion for the trial to be included in this review.

Types of interventions

Inclusion criteria

We will include all educational and training interventions that provide information to HCWs with the aim to change knowledge, behaviours and processes related to sharps injuries and splash occurrence. Educational interventions can range from simple printed information such as leaflets and posters to awareness-raising and intensive safety workshops. We will include studies that have education or training as an intervention alone or in combination with other intervention strategies.

Exclusion criteria

We will only consider studies if they distinguish outcomes attributable to the educational intervention or where the education component is the primary intervention.

Types of outcome measures

Primary outcomes

We will include studies that have evaluated the effectiveness of interventions on the exposure of workers to blood or bodily fluids in healthcare settings by sharps injuries or splash exposures. Trials may measure exposure using reports by the employer, self reports or empirical observations by researchers.

Secondary outcomes

  1. Reduction in observed cases of infections

  2. Improvement in knowledge related to sharps injuries and splash exposures as measured by surveys to HCWs

  3. Improvement in knowledge related to infectious disease transmission as measured by surveys to HCWs

  4. Adherence to organisations' occupational health and safety policies and procedures, as observed or reported

  5. Behavioural changes in clinical practice, as observed or reported

Search methods for identification of studies

Electronic searches

First, we will apply search terms for sharps injuries and splash exposures and then combine these with the recommended search strings for randomised trials and for non-randomised studies. For randomised clinical trials and controlled clinical studies, we will use the search strategy set forth in Robinson 2002. To find non-randomised studies we will use the sensitive search strategy for occupational health intervention studies (Verbeek 2005).

We will use the strategy to search CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL and OSH-update. In addition, we will search the databases of the World Health Organization (WHO), the UK National Health Service (NHS), Global Health, AustHealth and Web of Science.

We describe the search strategies to be used in the electronic databases in detail in Appendix 1.

Searching other resources

We will check the reference lists of all primary studies and review articles for additional references. We will also perform citation searching, citation trails and subject heading searching. We will contact experts in the field to identify additional unpublished materials.

Data collection and analysis

Selection of studies

Using the inclusion and exclusion criteria, two authors (SC, HL) will work independently to screen the titles and abstracts of the references yielded by the search strategy. We will obtain the full text of references that appear to meet the inclusion criteria. We will not apply blinding because we feel that this would not increase validity. We will solve disagreements by discussion. If disagreements persist, we will consult a third author (ST).

Data extraction and management

Two researchers (SC, HL) will use Covidence (Covidence) to independently extract study data. The two review authors will extract essential study characteristics about the participants, interventions, outcomes and results. We will also note any adverse events and the sponsorship of the study. Two authors (SC, HL) will independently assess the risk of bias of the studies and use a consensus method if disagreements occur. If disagreements persist, we will consult a third author (ST). We will not mask trial names because we believe that this would not increase validity.

Assessment of risk of bias in included studies

Two review authors (SC, HL) will assess risk of bias independently for each included study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We will resolve any disagreements by discussion or by involving another reviewer (ST). For the assessment of risk of bias in RCTs we will use the 'Risk of bias' tool in Review Manager (RevMan) software (RevMan 2014). In educational interventions blinding of participants is unfeasible. However, we will assess randomisation, allocation concealment, incomplete outcome data and selective outcome reporting as guided by Higgins 2011.

Assesment of bias in conducting the systematic review

We will conduct the review according to this published protocol and report any deviations from it in the 'Differences between protocol and review' section of the systematic review.

Measures of treatment effect

We will treat the results of each trial as dichotomous outcomes and we will plot them as risk ratios (RR) rather than odds ratios because the incidence of most outcomes will be higher than 10%. Sharps injuries can be sustained more than once and thus in some studies the reported rates will be larger than one per unit. Here, we will calculate the log rate-ratio and the standard error and use these data as inputs for RevMan (RevMan 2014), where we will combine them using the generic inverse variance method.

Unit of analysis issues

For studies that employ a cluster-randomised design but do not make an allowance for the design effect, we will calculate the design effect. If studies do not report the intra-cluster coefficients that are needed to calculate the design effect, we will assume a fairly large intra-cluster coefficient of 0.05 to enable the calculation of a design effect. We will use the methods that are recommended in Higgins 2011.

Dealing with missing data

If data needed for meta-analysis are missing, we will contact the authors for additional information. If data are presented in figures only and we cannot contact authors, we will extract data from the figures presented in the article. If data such as standard deviations are missing and can be calculated from other data present in the article such as P values, we will do so according to the recommendations in Higgins 2011.

Assessment of heterogeneity

We will define studies to be sufficiently homogeneous when they have similar populations, interventions and outcomes measured at the same follow-up point. We will consider all healthcare workers as sufficiently similar to assume a similar preventive effect from education and training.

We will divide outcomes into number of exposures, number of infections, and changes in knowledge or behaviour. We deem all educational and training interventions within these categories to be conceptually similar and sufficiently homogeneous to be combined in a meta-analysis.

We will not combine various study designs, as we assume that there will be large differences in the risk of bias between different study types. Hence, we will present the results per comparison separately per design type.

We will assess statistical heterogeneity by means of the I2 statistic. We will use the values of < 40%, between 30% and 60%, between 50% and 90%, and over 75% as indicating not important, moderate, substantial and considerable heterogeneity, respectively, as proposed in Higgins 2011.

Assessment of reporting biases

We will assess publication bias with a funnel plot if more than five suitable studies are available for inclusion in the plot.

Data synthesis

We will pool studies with sufficient data that we judge to be homogeneous by design and statistically speaking, using RevMan software (RevMan 2014). We will use a random-effects model when studies are statistically heterogeneous; otherwise we will use fixed-effect model.

Finally, we will use the GRADE approach to assess the quality of the evidence per comparison and per outcome as described in Higgins 2011. We will reduce the quality of evidence by one or more levels if there are limitations in one or more of the following domains: risk of bias, consistency, directness of the evidence, precision of the pooled estimate and the possibility of publication bias. For the two most important outcomes, the number of exposures and number of observed cases of infections, we will use the GRADEproGDT programme to generate 'Summary of findings' tables (GRADEproGDT 2014).

Subgroup analysis and investigation of heterogeneity

First, we will analyse whether there is a difference in intervention effect in workers with different levels of exposure, which we will categorise as low or high exposure. We will assess different levels of exposure to sharps injuries and splashes through occupation and prevalence of viral infection in the workplace setting. Examples of professionals at higher risk are surgeons due to the sharps instruments used and HCWs in developing countries due to higher disease prevalence and lack of resources for prevention. Secondly, we will classify the educational interventions according to their level of engagement to either a low or high level of engagement. For this subgroup analysis, we will consider both medium- and high-intensity training to constitute a high engagement intervention.

Sensitivity analysis

For a sensitivity analysis, we will analyse the results again, including only studies we judge to have a low risk of bias. We will categorise studies based on their design as described above in Types of studies.

Acknowledgements

We would like to acknowledge and thank the previous authors of this protocol Manisha Pahwa (the University of Toronto), Marie-Claude Lavoie (the University of Maryland Baltimore) and Jos Verbeek (Cochrane Work Review Group). We would also like to thank Jos Verbeek for his guidance and advice when developing this protocol, and Jani Ruotsalainen (Cochrane Work Review Group) for providing support and information to the authors.

Appendices

Appendix 1. Search strategies

1. Search strategies

The Cochrane Hepato-Biliary Group Controlled Trials Register

('health care worker*' or 'HCWs' ) and ( 'virus disease*' or 'virus*' or 'viral infect*')

EMBASE

#7 #6 AND [humans]/lim AND [embase]/lim

#6 #4 AND #5

#5 [randomized controlled trial]/lim OR [controlled clinical trial]/lim OR random* OR 'double blind' OR 'single blind' OR (singl* OR doubl* OR trebl* OR tripl* AND (blind* OR mask*)) OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'triple blind procedure'/exp OR placebo* OR 'controlled study'/exp OR 'cross sectional study'/exp OR 'crossover procedure'/exp OR 'latin square design'/exp OR 'follow up'/exp OR 'comparative study'/exp OR 'evaluation studies'/exp OR 'evaluation study' OR prospectiv* OR volunteer*]

#4 #1 AND #2 AND #3

#3 ‘education’/exp OR ‘train’/exp OR ‘learn’/exp OR ‘teach’/exp OR ‘course’/exp

#2 'health care worker'/exp OR 'health care worker' OR 'health care workers' OR 'health care facilities and services'/exp OR 'medical profession'/exp OR 'nursing as a profession'/exp OR ('virus transmission'/exp AND 'patient'/exp AND professional)

#1 'needlestick injury'/exp OR needlestick* OR 'needle stick'/exp OR 'sharp injury' OR 'sharp injuries' OR 'sharp medical' OR 'sharp instrument' OR 'sharp needle' OR 'sharp needles' OR sharps OR 'percutaneous exposure' OR 'percutaneous injury' OR 'percutaneous injuries' OR 'percutaneous trauma' OR 'stick injury' OR 'stick injuries' OR 'stab wound'/exp OR 'face injury'/de OR 'eye injury'/de OR 'arm injury'/de OR 'hand injury'/de OR 'needle'/exp OR (splash* AND ('blood'/exp OR blood OR secretion* OR fluid* OR 'body fluid'/exp OR 'body fluids'/exp))

Wiley InterScience:

Cochrane Library Databases:

CENTRAL and NHSEED

#4 #1 AND #2 AND #3

#3 EXP education OR train* OR teach* OR learn* OR course*

#2 EXP Needlestick Injuries (MeSH) OR needlestick* OR "needle stick" OR "needle sticks" OR "percutaneous exposure" OR "percutaneous exposures" OR "percutaneous injury" OR "percutaneous injuries" OR "stick injury" OR "stick injuries" OR Wounds, Stab (MeSH) OR Wounds, Penetrating (MeSH) OR Facial injuries (MeSH) OR EXP Eye Injuries, Penetrating (MeSH) OR Forearm Injuries (MeSH) OR EXP Hand Injuries (MeSH) OR [splash* AND blood OR secretion* OR fluid* OR EXP Body Fluids (MeSH) OR EXP Bodily Secretions (MeSH)]

#1 EXP Health Occupations (MeSH) OR EXP Health Facilities (MeSH) OR "health care worker" OR "health care workers" OR Infectious Disease Transmission, patient-to professional (MeSH)

Science Citation Index Expanded

#5 #1 AND #2 AND #3 AND #4

#4 TS=(random* OR control* OR trial OR trials OR "single blind" OR "double blind" OR "triple blind" OR "latin square" OR placebo* OR comparative OR "follow up" OR prospectiv* OR "cross over" OR volunteer*)

#3 TS=(education* OR train* OR learn* OR teach* OR course*)

#2 TS=(needlestick* OR "needle stick" OR "needle sticks" OR "stick injury" OR "stick injuries" OR "wound stab" OR "stab wound" OR "penetrating wound" OR "penetrating wounds") OR TS=(sharp* AND ( injury OR injuries OR medical OR instrument*)) OR TS=(percutaneous AND (exposure OR exposures OR injury OR injuries)) OR TS=(injur* AND (facial OR eye OR eyes OR arm OR hand OR finger OR fingers)) OR TS=(splash* AND (blood OR secretion* OR fluid OR fluids)) OR TS="blood borne infection"

#1 TS=("health care worker" OR "health care workers" OR "health occupations" OR physician* OR nurse* OR hospital* OR clinic OR clinics)

CINAHL

#6 #4 AND #5

#5 "randomized controlled trial" or "clinical trials" or "clinical trial" or "random allocation" or "double blind". or "single blind" or ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or "latin square" or placebo# or random* or "research design" or "comparative study" or "comparative studies" or "evaluation study" or "evaluation studies" or "follow up study" or "follow up studies" or "prospective study" or "prospective studies" or "cross over study" or "cross over studies" or control* or prospective* or volunteer or (MH "Clinical Trials+") or (MH "Nonrandomized Trials") or (MH "Crossover Design")

#4 #1 AND #2 AND #3

#3 “education” OR “train#” OR “learn#” OR “teach#” OR “course#”

#2 TX "needlestick injury" or needlestick# or "needle stick" or "needle sticks" or "sharp injury" or "sharp injuries" or "sharp medical device" or "sharp medical devices" or "sharp instrument" or "sharp instruments" or "sharp needle" or "sharp needles" or "percutaneous exposure" or "percutaneous exposures" or "percutaneous injury" or "percutaneous injuries" or "stick injury" or "stick injuries" or "wounds, stab" or "wounds, penetrating" or "facial injuries" or "eye injuries, penetrating" or "arm injuries" or "forearm injuries" or "hand injuries" or "finger injuries" or (splash# and (blood or secretion# or fluid#)) or ("occupational exposure" and ("body fluid" or "body fluids" or blood))

#1 (MH "Health Occupations") OR health occupations or (MH "Health Personnel+") or (MH "Health Facilities+") OR health facilities or TX "health care worker" or TX "health care workers" or (MH "Personnel, Health Facility+") or (MH "Occupational Health Services+") or (MH "Occupational Hazards+") or (MH "Occupational Exposure") or (MH "HIV Infections+")

OSH UPDATE (NIOSHTIC-2 and CISDOC) NIOSHTIC-2

CISDOC

#14 #7 AND #12 AND #13

#13 GW{education* OR train* OR learn* OR teach* OR course}

#12 #8 OR #11

#11 #9 AND #10

#10 GW{blind* OR mask*}

#9 GW{singl* OR doubl* OR tripl* OR trebl*}

#8 GW{random* OR control* OR trial OR trials OR comparativ* OR evaluation* OR "latin square" OR placebo OR "follow up" OR prospectiv* OR "cross over" OR volunteer*}

#7 #1 AND #6

#6 #2 OR #5

#5 #3 AND #4

#4 GW{splash*}

#3 GW{blood OR fluid* OR secretion*}

#2 GW{"sharp medical" OR "sharp instrument" OR "sharp instruments" OR needlestick* OR "needle stick" OR "needle sticks" OR "sharp injury" OR "sharp injuries" OR "stab wound" OR "stab wounds" OR "wound penetrating" OR "stick injury" OR "stick injuries" OR "percutaneous injury" OR "percutaneous injuries" OR "percutaneous exposure" OR "percutaneous exposures" OR "sharp needle" OR "sharp needles"}

#1 GW{nurse OR nurses OR physician OR physicians OR hospital* OR "health occupation" OR "health occupations" OR "health care worker" OR "health care workers" OR "health worker" OR "health workers"}

MEDLINE in PubMed

#6 Search #1 AND #2 AND (#3 OR #4) AND #5

#5 Search education*[tw] OR train*[tw] OR learn*[tw] OR teach*[tw] OR course*[tw]

#4 Search effect*[tw] OR control[tw] OR controls*[tw] OR controla*[tw] OR controle*[tw] OR controli*[tw] OR controll*[tw] OR control'*[tw] OR evaluation*[tw] OR program*[tw]

#3 ("Randomized Controlled Trial"[pt] OR "Controlled Clinical Trial"[pt] OR "Randomized Controlled Trials as Topic"[mh] OR "Random Allocation"[mh] OR "Double-Blind Method"[mh] OR "Single-Blind Method"[mh] OR "Clinical Trial"[pt] OR "Clinical Trials as Topic"[mh] OR "clinical trial"[tw] OR ((singl*[tw] OR doubl*[tw] OR trebl*[tw] OR tripl*[tw]) AND (mask*[tw] OR blind*[tw])) OR "latin square"[tw] OR Placebos[mh] OR placebo*[tw] OR random*[tw] OR "Research Design"[mh:noexp] OR "Comparative Study"[pt] OR "Evaluation Studies as Topic"[mh] OR "Follow-up Studies"[mh] OR "Prospective Studies"[mh] OR "Cross-over Studies"[mh] OR control[tw] OR controls*[tw] OR controla*[tw] OR controle*[tw] OR controli*[tw] OR controll*[tw] OR control'*[tw] OR prospectiv*[tw] OR volunteer*[tw]) NOT (Animals[mh] NOT Humans[mh)

#2 "Needlestick injuries"[mh] OR needlestick*[tw] OR "needle stick"[tw] or "needle sticks"[tw] OR "sharp injury"[tw] OR "sharp injuries"[tw] OR sharps[tw] OR "sharp medical device"[tw] OR "sharp medical devices"[tw] OR "sharp instrument"[tw] OR "sharp instruments"[tw] OR "sharp medical instrument"[tw] OR "sharp medical instruments"[tw] OR "sharp needle"[tw] OR "sharp needles"[tw] OR "percutaneous exposure"[tw] OR "percutaneous exposures"[tw] OR "percutaneous injury"[tw] OR "percutaneous injuries"[tw] OR "stick injury"[tw] OR "stick injuries"[tw] OR "Wounds, Stab"[mh:noexp] OR "Wounds, Penetrating"[mh:noexp] OR "Facial injuries"[mh:noexp] OR "Eye Injuries, Penetrating"[mh] OR "Arm Injuries"[mh:noexp] OR "Forearm Injuries"[mh:noexp] OR "Hand Injuries"[mh] OR (splash* AND (blood[tw] or secretion*[tw] OR fluid*[tw] OR "Body Fluids"[mh]))

#1 "Health Occupations"[mh] OR "Health Facilities"[mh] OR "health care worker"[tw] OR "health care workers"[tw] OR "Infectious Disease Transmission, Patient-to-Professional"[mh]

Contributions of authors

Conceiving the protocol: SC, HL, ST, JL

Designing the protocol: SC, HL, ST, JL

Coordinating the protocol: SC

Designing search strategies: HL

Writing the protocol: SC, HL, OA

Providing general advice on the protocol: HL, ST, JL

Declarations of interest

Shelley Cheetham: None known.

Sandra Thompson: None known.

Juha Liira: None known.

Helena Liira: None known.

Olugbenga Afilaka: None known.

Ancillary

Article Information

DOI

10.1002/14651858.CD012060

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Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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References

Additional references

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Citing Literature

  • Number of times cited: 3
  1. 1Bao Yen Luong Thanh, Malinee Laopaiboon, David Koh, Pornpun Sakunkoo, Hla Moe, Malinee Laopaiboon, Cochrane Database of Systematic Reviews, 2016Wiley Online Library
  2. 2AbdullahM Al Jarallah, AmaniS Ahmed, Risk management approach of needle stick and sharp injuries among nurses, Saudi Arabia: An interventional study, Journal of The Arab Society for Medical Research, 2016, 11, 2, 50CrossRef
  3. 3Annika Saarto, Jos H Verbeek, Marie-Claude Lavoie, Manisha Pahwa, Annika Saarto, Cochrane Database of Systematic Reviews, 2011Wiley Online Library