A hospital’s exposure control plan must be reviewed at least once every 12 months and whenever job tasks or technology change.
Hospitals live by routine. Blood draws, injections, cleaning, transport—each step carries risk. An exposure control plan (ECP) turns those risks into clear rules. The question that drives compliance leaders is simple: how often should the plan be checked and refreshed so it matches the real work on the floor?
You don’t need guesswork. Federal rules set a baseline review cycle, and daily changes in devices, roles, and workflows can bring earlier updates. The sections below give you the required cadence, the triggers that demand a mid-year edit, and a clean way to document it so audits go smoothly.
How Often Should A Hospital’s Exposure Control Plan Be Reviewed: OSHA’s Rule And Triggers
Under OSHA’s Bloodborne Pathogens Standard, hospitals must review and update the ECP at least once every year. The plan also needs an update whenever jobs, procedures, or technology change in ways that affect exposure to blood or other potentially infectious materials. That means the calendar isn’t the only driver; real-world changes start the clock too.
| Trigger | What It Means Day-To-Day | Proof To Keep |
|---|---|---|
| Annual cycle | Plan gets a full pass once every 12 months | Signed review log and version date |
| New or modified tasks | Unit adds steps that raise splash, sharps, or specimen handling | Updated exposure determination and SOPs |
| New or revised job roles | Positions with exposure are added or reshaped | Revised job list in the plan |
| Technology changes | New sharps, closed systems, or safety features reach the units | Device evaluation notes and selection form |
| Safer device review | Annual check that safer options were weighed and, when feasible, adopted | Documented annual review of safer devices |
| Post-incident learning | Exposure event reveals a gap that needs a fix | Incident review and change record |
One more rule ties into the review. Hospitals must ask non-managerial clinical staff for input on safer devices and controls. Frontline voices help match the plan to the reality of phlebotomy, bedside injections, and waste handling.
Who Owns The Review In A Hospital
Most hospitals anchor the review in infection prevention and employee health, with safety or EHS as co-owners. Nursing leaders, lab leaders, and perioperative teams bring the unit detail. Supply chain and biomed add device data. HR or education plugs in for training dates and rosters. One person still needs the pen: a named owner who collects edits, routes the draft, and signs the final copy.
Pick a month that fits your survey window and staffing surge cycles. Many teams run the review just after the annual device fair or sharps committee meeting, once evaluations are fresh and receipts are handy.
What To Check During The Annual Update
The annual pass isn’t just a date change. Walk through the plan against how care is actually delivered. These checkpoints keep the review tight and complete.
Exposure Determination
Confirm the list of job titles with exposure. Then map the tasks that bring contact with blood or body fluids. Phlebotomy, IV starts, specimen transport, cleaning of contaminated rooms, and lab prep are common entries.
Engineering Controls And Safer Devices
Check the current mix of safety needles, needleless IV access, sharps containers, closed blood collection, and splash guards. Verify that safer options were weighed during the year and document the selection. If a trial happened, add the results and the decision.
Work Practices And PPE
Reaffirm no-recap rules, one-hand scoop where permitted, transport in rigid containers, and room cleaning steps. Review PPE by task: gloves, gowns, eye and face protection. If units changed workflows, reflect that shift in the text.
Housewide Training
Training runs at hire and then every 12 months for staff with exposure. Match your plan’s statements with learning records. If modules moved from classroom to online, say so. If content changed, list the topics to keep the plan synced with the program.
Post-Exposure Care
Make sure reporting steps, source testing, employee testing, and prophylaxis lines are current and easy to follow. Phone numbers and on-call paths drift; fix those while you’re here.
Linking The Plan To The Rule
Two sources anchor the cadence and content. The OSHA Bloodborne Pathogens rule spells out the annual review and the need to update for job, procedure, and technology changes. The CDC sharps safety workbook gives handy tools for device evaluation and program checks. Linking your plan text to these two anchors keeps it aligned with regulators and best practice.
See the OSHA Bloodborne Pathogens standard for the exact review language, and use the CDC’s sharps injury prevention workbook to structure device reviews and track outcomes.
Handling Mid-Year Changes Without Waiting
Don’t sit on changes until the anniversary date. If a unit adds ultrasound-guided IVs, swaps needle models, opens a new clinic, or moves to closed blood collection, publish an update now. Push the new steps in huddles, print fresh pocket cards, and post the revised PDF where staff expect it. Keep the annual pass on the calendar; the mid-year edits roll into that master review.
How Often Should A Hospital Exposure Control Plan Be Reviewed: Practical Cadence By Area
Every area follows the same rule, but the pace of change varies. Periop might change devices once a year. ED and ICU see trials more often. Lab, dialysis, and interventional suites run specialized steps that need closer tracking. Use the list below to plan touchpoints through the year.
- Emergency and critical care: frequent device trials; set quarterly check-ins with the sharps committee.
- Perioperative areas: align plan edits with vendor fairs and new tray builds.
- Laboratory: sync with analyzer swaps and specimen transport routes.
- Dialysis: track vendor changes, access needle types, and waste handling.
- Phlebotomy and units: tie updates to supply conversions and container placements.
Documentation That Survives Audits
Auditors and surveyors want to see two things: proof that the plan was reviewed on time, and proof that device choices and changes were real and staff-driven. Keep a slim packet for each year with the items below. Store it where survey teams can reach it fast.
- Signed review form with date, names, and version ID
- Exposure determination list with updated roles and tasks
- Sharps device evaluation summaries and meeting notes
- Training outline, dates, and completion data
- Incident trend snapshots and any plan changes tied to them
- Distribution proof: link to the plan and change notice
Second Table: Annual Review Timeline And Owners
| Step | Owner | What To Produce |
|---|---|---|
| Set date and scope | Infection prevention | Calendar invite and task list |
| Refresh exposure determination | Unit leaders | Updated roles and task matrix |
| Sharps device review | Sharps committee | Evaluation forms and decision note |
| Policy and SOP edits | EHS and units | Redline and clean copy |
| Training sync | Education | Outline and roster plan |
| Sign-off and publish | Plan owner | Signed PDF with version date |
| Staff notice | Unit educators | Huddle script and intranet post |
| File records | Compliance | Packet with all proofs |
Common Missteps That Delay Compliance
Missed dates come from fuzzy ownership and scattered records. Set one owner, one folder, and one version ID. Another trap is changing devices without closing the loop in the plan. When supply swaps a needle, the plan text, SOPs, and training need the same change. Last, plans often lag on contact details. Make a quick sweep of phone trees and URLs during each pass.
Real-World Triggers That Force An Update
Here are everyday events that push an edit before the annual pass. Treat each as a small change request so the plan never drifts away from practice.
- New patient care site opens, such as a short-stay unit or fast-track clinic
- Switch to a new safety needle, closed system, or container supplier
- Introduction of blood gas cartridges with built-in needles
- Workflow change that moves specimen prep from lab to unit or vice versa
- New role added with exposure, such as a vascular access team
- Exposure event that reveals a gap, leading to a revised step
How To Keep The Plan Visible
Put the current version on a stable intranet path. Link it from unit pages and training modules. Add the version date to the footer so staff can check freshness at a glance. Keep a short change log on page one with dates and a quick note on what shifted.
Simple Annual Review Agenda
A short, repeatable agenda keeps meetings brisk and productive. Book a 60–90 minute slot. Invite unit leads, sharps committee reps, and education. Share the draft a week ahead so edits land before the call.
- Five minutes: confirm scope and version ID
- Fifteen minutes: walk the exposure determination updates
- Twenty minutes: device evaluation results and purchase plans
- Fifteen minutes: training method, content, and completion data
- Ten minutes: incident trends and any step changes
- Ten minutes: open items, owners, and due dates
Metrics That Show The Plan Works
Pick a small set of measures and trend them each quarter. Numbers tell the story.
- Sharps injuries per 100 full-time equivalents
- Blood and body fluid exposure reports per 10,000 patient days
- Training completion within 12 months of prior session
- Device trial outcomes and adoption rate
- Audit scores for container placement and fill levels
- Turnaround time from plan change to staff notice
Takeaway
A hospital’s exposure control plan needs a full review once every 12 months and fresh edits when jobs, procedures, or technology shift. Tie the plan to device evaluations and staff input, keep clean records, and publish changes fast. With that cadence, the plan stays aligned with how care is actually delivered—and your next audit reads like a formality.