Needlestick Injuries and Other Blood-borne and/or Body Fluid Pathogen Exposures Policy

Purpose

To educate about, prevent, and address student blood and /or body fluid exposures and environmental hazards.

Overview

All healthcare workers are at potential risk from exposure to blood and/or body fluids. Students must be educated about risks, prevention, and treatment of exposures. It is recommended that Universal Precautions be adopted whenever there is the potential for exposure to reduce the risk of transmission of pathogens. There are validated protocols to reduce the risk of transmission in the event of an exposure to HIV, HBV, or HCV; an accessible, clear protocol must be outlined and disseminated to all students. Students may also encounter environmental and workplace hazards during educational activities. UCSF workplace safety and environmental
protection requirements apply to students, including at remote sites. Students are expected to identify and promptly report unsafe conditions or hazardous releases and to follow applicable safety procedures and guidance from the responsible site and UCSF Office of Environment, Health and Safety (EH&S).

Related LCME Standards

12.8: Student Exposure Policies/Procedures

Principles

The education of medical students about methods exposure prevention; procedures for care and treatment after exposure; definition of financial responsibility in care and treatment; and the effects of infectious and environmental disease or disability on learning activities must all be addressed. This includes education and guidance regarding applicable environmental and workplace hazards and the appropriate response to unsafe conditions or exposures.

Policy

 

  1. Students are introduced to the concept of infection control and work-related exposure during their first year of medical school. Education and training regarding exposures will be updated annually throughout medical school. Education and training regarding exposures will be updated annually throughout medical school, including applicable infectious and environmental hazards.
  2. Students must immediately report potentially unsafe practices, serious hazards, and environmental releases associated with their educational activities to the appropriate supervisor or instructor and/or EH&S, consistent with site-specific procedures. Students may stop work that appears unsafe until proper safety precautions are implemented. Work presenting an imminent hazard may be stopped immediately and may proceed only when safe conditions have been established.
  3. Students, including visiting students, must contact the UCSF Needlestick Hotline 24 hour pager immediately in the event of an exposure to blood and/or bodily fluid. The contact number [(415) 353-STIC (7482)] is listed on the student ID insert.
  4. There are standardized protocols for exposures at UCSF / in San Francisco and at non-UCSF facilities / our-of-area facilities addressing exposure to HIV, HBV and HCV. Financial coverage of treatment is outlined in the protocol.
  5. Students who are infected with any other potentially transmissible disease will not be excluded from participating in patient-care activities, or restricted in their access to patient-care services or facilities because of their health status, unless medically-based judgments in individual cases establish that exclusion or restriction is appropriate for the welfare of patients, the welfare of other members of the patient-care community, or the welfare of the individual. 

 

Procedure

  1. Needlestick procedures are included in a mandatory policy attestation process for students.* These procedures are posted in the student handbook and on the policy page on the UCSF website with links in iRocket. Applicable environmental hazard and
    workplace safety information will be incorporated into student safety education and orientation materials and updated as needed.
  2. Information about the Blood and Body Fluid Exposure policy is included on student badges distributed during Launch Week.
  3. Blood and Body Fluid Exposure procedures are introduced during the Clinical Microsystem Clerkship Procedures session (122C).
  4. During orientation to the clerkships, clerkship directors/site directors review needlestick procedures with students. Students also re-attest to understanding this policy prior to starting their clerkships.  
  5. Students have the ability to report hazards anonymously. Anonymous reporting can be submitted through the following portal.

 

Related Policies

https://policies.ucsf.edu/policy/550-26

Accountable Dean or Director:

Associate Dean for Students
Executive Director, Assessment, Curriculum, Evaluation (incorporation into curriculum)
Director of Student Experience Team (visiting students)

Approval Date and Governing Body: October 13, 2026, CCEP