Bloodborne Pathogens

Medical Records

Exposure Control Plan

Required elements:

  1. Exposure determination identifying job classifications with occupational exposure and the specific tasks/procedures where exposure occurs.
  2. Procedures for evaluating circumstances of exposure incidents.
  3. A schedule of how other provisions of the BBP standard are implemented.  Methods of compliance include:
    1. Universal Precautions
    2. Engineering and work practice controls
    3. PPE
    4. Housekeeping (decon. & waste removal)
  4. Documentation of:
    1. Annual consideration/implementation of safer medical devices
    2. Solicitation of non-managerial employees representing all areas where exposure can occur in updating engineering and work practice controls.
  5. Reviewed and updated annually and when tasks/procedures/positions change.

Removing BBP

Sources of Terminology

Terms Related to Removal of BBP

Surfaces (non-living) Living Tissue Both
Disinfectants Antibiotics Biocides
Sanitizers Antiseptics


  • Destroys all microorganisms including large numbers of resistant bacterial spores.


  • Destroys most microorganisms but not necessarily all microbial forms, such as bacterial spores.


  • Combination of cleaning and disinfecting the surface.

Sterilization  >  Disinfection  ≈  Sanitization

Types of Removing Agents


Modifications to the BBP standard required under the Needlestick Safety and Prevention Act

Categorized into four categories:

  1. Modification of definitions relating to engineering controls;
  2. Revision and updating of the Exposure Control Plan;
  3. Solicitation of employee input; and
  4. Recordkeeping

1.  Modification of definitions relating to engineering controls

  • Added "Sharps with Engineered Sharps Injury Protections"
  • Added "Needleless Systems"
  • Modified "Engineering Controls" by adding "safer medical devices…."

2.  Revision and updating of the Exposure Control Plan

  • During annual review and update of the ECP, consider new technology that may be safer and document this consideration and, if applicable, implementation.

3.  Solicitation of employee input

  • Solicit non-managerial  employees who are responsible for direct patient care for input on engineering controls and work practice controls.
  • Not all employees but a representation of all ranges of exposure types.
  • Document this solicitation.

4.  Recordkeeping

  • Require a sharps injury log; except for those not required to keep injury and illness logs (OSHA-300/301).
  • Minimum info: Device involved, location of incident, description of events
  • Log can contain personal info but only if employee's personal info is withheld when sharing data with other parties.
  • No specific format required.
  • OSHA-300 logs and 301 forms can be used as long as:
    • Type and brand of device is included (either 300 or 301)
    • Recorded in such a way that it segregates sharps sticks from other illness/injuries; or allows them to be easily separated (e.g., computer filter; separate page of paper; etc.)
  • 1904.8 already requires sharps injuries involving contaminated instruments to be recorded in 300/301 forms.


  • If any potentially infectious material is released on to a surface that may be contacted by employees, that surface must be disinfected. (Diane's email 1/29/2014)