For patients and visitors, an actual exposure to blood or body substances includes parenteral, mucous membrane, or skin contact (regardless of whether the skin is intact or broken). A potential exposure to blood or body substances involves incidents whre there was a "near miss" in that contact did not actually occur but the potential for contact was significant.

1. If a patient or visitor sustains and actual exposure to blood or body substances:
   

   	Notify the attending and/or resident physician if the incident involves a patient.
   	Notify the Hospital Epidemiology (8-4634).
   	Assist the visitor who was exposed to blood or body substances to the Emergency Room for evaluation and treatment.

   
   
2. If an incident occurs where a patient or visitor was potentially exposed to blood or body substances, the employee discovering the potential exposure occurrence should complete a "Report of Incident" form (F-877) as soon as possible and present it to his/her supervisor. The report must be forwarded to the Central Nursing Office within 24 hours if the exposure incident occurred on a patient care unit. If the exposure incident occurred in any other hospital area, forward this report directly to the Department of Risk Management.
   
   
3. Follow-up should be patterned after the protocol established for employees with significant blood or body fluid exposures.