MIDDLE GROUND Neutral zones and hands-free passing limit sharps injury risk.

Most surgical professionals think they'll never get stuck by a needle or cut by a scalpel but, in reality, many of us have. As these 6 scenarios show, sharps injuries can happen to anyone, at any time. I learned of the following actual events over the last 3 years while studying sharps safety as chair of the AORN Clinical Nursing Practice Committee. You'll notice that these injuries could have been prevented if those involved had used safety-engineered devices and remained focused on the situation at hand.

The collision

During a right knee ligament reconstruction on a 17-year-old patient, the surgeon uses a drill and unexpectedly puts it down on an instrument table just as the surgical tech, who's double-gloved, picks up another instrument. The drill's bit nicks the tech's right palm, opening a small cut.

The tech's hand happened to be passing through the area where the surgeon was placing the drill. Did unfortunate luck play a role in this injury? Sure, but it could have been prevented if both the surgeon and tech practiced proper sharps handling practices, including the use of a neutral zone and hands-free passing. The surgeon could have announced that he was placing the drill back on a neutral zone, while the tech could have paid closer attention to the action on the surgical field because a sharp was being used. Avoiding distractions, observing the surgeon's movements and ensuring her hands were clear of the neutral zone would have helped her anticipate his next move.

Individual surgical teams must establish where the neutral zone — comprised of a basin, towel, small instrument table or magnetic or custom-made pad — is located, depending on patient positioning, before each case. Announce the zone's location during pre-op briefings and how instruments will be passed through it.

Hands-free passing is ideal, during which communication is key. Surgeons and techs should announce "sharp coming" or "sharp back" — or whatever verbal warning works best for them, as long as it's agreed upon at the start of the case — whenever they place items in the neutral zone. When the passing of sharps directly into a surgeon's hand is necessary — if he's peering through a surgical microscope and can't break his field of vision, for example — alert him that the item is coming and place it using his preferred method.

The needlestick

A 68-year-old female patient needs an injection of subcutaneous heparin before a bilateral mastectomy procedure. The heparin injection cartridge used by the nurse is not a safety device. After giving the injection, the nurse places the needle cap on an instrument table and inserts the needle into the cap. As the nurse prepares to dispose of the syringe into a sharps container and removes the syringe cartridge from the holder, the cap dislodges and the dirty needle pokes the nurse's finger.

This situation was complicated by the number of people surrounding the patient. The nurse was likely distracted and perhaps didn't realize the cap wasn't on securely. Additional focus on ensuring safe removal and disposal of needle cartridges is very important. If recapping is absolutely necessary, use a single-handed technique to reattach the cap. Also known as the "scoop" technique, you place the cap on a hard surface, or in a custom holder, and place the needle tip into the cap without using your free hand to guide the process. That eliminates the possibility of sticks occurring if the needle slips from the cap or passes through it during recapping. A better practice is using a safety cartridge with a shield that automatically or manually flips over the needle tip after its use.

A few related notes: Place sharps containers close to where sharps are used so they can be disposed of immediately, empty the containers regularly and don't let them become overfilled.

The reprocessing tech

A sterile processing tech prepares a tray of used surgical instruments for the washer-decontaminater. The instruments are a tangled mess, with items simply piled in the tray. The tech is wearing proper PPE, although he's wearing only 1 pair of gloves. As he tries to separate 2 instruments, he catches his thumb on a Senn rake retractor, which perforates his glove and punctures his skin. The reprocessing department's supervisor is unable to identify on which patient the instruments were used.

Never underestimate or overlook sharps injury risk in the sterile processing department. The dangers of injuries sustained in the reprocessing area are magnified because it can be difficult to trace instruments back to which cases they were used in and, therefore, to get proper assessments of cross-contamination risks from potentially infected patients.

Remind your sterile processing staff to always wear proper PPE, including double-gloves (which the tech in this case didn't do), and that seemingly harmless instruments such as rake retractors, nerve hooks, osteotomes and scissors can cause serious injury. There are also more durable gloves available on the market that are intended for instrument decontamination, which also could have lowered injury risk in this situation.

Your surgical team must also be accountable for properly preparing instrument trays for transport to the reprocessing department. Organize used instruments and place the instruments back in trays just like they were delivered to the OR, so reprocessing techs don't have to separate a tangle of dangerous sharps. Because the tray was returned carelessly in this scenario, the tech should have used another instrument, instead of his fingers, to separate and sort the items.

The reprocessing department's supervisor wasn't able to identify from which OR the instruments came. Avoid similar issues in your facility by having a system in place to link instrument sets to particular cases, whether that involves dropping a note with the case number on the used instruments or some sort of color-coded magnet that's stuck to trays before they leave the ORs.

The distracted anesthesiologist

A 54-year-old patient is being prepared for a left inguinal hernia repair. The patient has a long history of chronic back pain, opioid use, alcohol abuse and illegal drug use. A seasoned 64-year-old anesthesiologist, who refuses to use safety needles or change his technique, performs a spinal (subarachnoid) block. After injection of the local anesthetic, the anesthesiologist's pager goes off as he tries to recap the needle. As he reaches for the pager, the needle sticks his left forefinger.

Another needlestick resulting from recapping issues, but this time the injury occurred during placement of a regional block in a procedure area, a stark reminder that dangers do exist outside of the OR.

The anesthesiologist was unwilling to use a safety-engineered device, which was his first mistake. He also should have used a single-handed recapping technique. Finally, he should have ignored all distractions. When handling sharps, focus only on the task at hand. That might seem like obvious advice, but as this example shows, sometimes the most obvious precautions are ignored in the hustle and bustle of surgery. If your pager's going off, wait until you're done handling the sharp and its tip or blade is covered or secured before turning it off.

Anesthesiologists don't get stuck as much as surgeons or surgical team members do, but make sure they understand the danger exists and have them take necessary precautions, including the use of safety-engineered needle systems — there are plenty of effective devices on the market today that protect users from needlesticks after injections are made.

The selfish surgeons

A 72-year-old male patient has multiple medical problems, including liver function abnormalities and renal failure, and is hepatitis C positive. During a brachiocephalic fistula procedure, the group of vascular surgeons working the case passes the surgical tech a bunch of very fine sutures and needles at once. The tech has to grab the mass without the required care, resulting in a needlestick in her palm.

The physicians involved in this case tied and cut a series of sutures and passed them back to the tech all together, which isn't an ideal practice from a sharps safety perspective. Double-armed vascular sutures have needles at each end, which increases injury risks for techs. This wasn't an emergent case, so the surgeons could have used more care when returning the multiple fine needles and sutures back to the tech. They should have handed the needles back one at a time or, alternatively, dropped them into a basin or magnetic suture collection device instead of the tech's hand. (Blunt suture needles wouldn't have been effective on vessels in this case, but are perfectly acceptable and recommended for closing muscle and fascia.)

This scenario highlights the importance of keeping surgeons informed about sharps safety. Ramon Berguer, MD, FACS, a well-known surgeon advocate for sharps safety, says it's unfair for 1 team member to make a choice that puts other team members at risk. Educate your nurses and techs, but also emphasize to surgeons that their actions, such as using safe sharps handling, or inactions, such as refusing to use safety-engineered devices, put all surgical team members at risk.

Most surgeons are trainable in sharps safety if you present them with data to show how real the risks are and how effective even the simplest changes to their practices can be. The AORN Sharps Safety Toolkit contains the evidence-based data they desire.

The scalpel slice

During a routine laparoscopic cholecystectomy, the veteran surgeon makes the initial incision with a non-safety scalpel and places it back on the instrument table, with the #11 blade pointed away from the surgical tech. The tech reaches for additional supplies from the circulating nurse and doesn't see the knife placement. The tech then passes a trocar to the surgeon, and as she brings her arm back, the knife's point catches on her gown sleeve and stabs her in the forearm.

The surgeon correctly laid the knife down with the blade pointing away from the tech, but placing it in a neutral zone would have been better because that's where the tech would expect a knife to be. The tech was clearly distracted by reaching for other supplies, but that's the nature of surgery. Expect distractions to happen and take necessary precautions to ensure staff is always protected, especially when working in a busy OR.

Safety scalpel designs that cover blades when the knives aren't in use would have avoided all the trouble in this situation. Manufacturers have worked hard to improve the feel and functionality of safety scalpels — protective sheaths are easier to engage with a single hand or slide over blades automatically, and some handles are weighted like conventional scalpels — so have your surgeons give them another look if they've been unimpressed by previous generations.

The overall safety culture at your facility also impacts your surgeons' opinions of safety scalpels. Initiate safety scalpel trials and encourage their use at the front line. Have surgeons practice handling the latest options before taking them into the OR — they might be surprised at how useful they are in practice. Even if safety blades don't have the same feel of standard scalpels, it's safer for us all if surgeons use them, at the very least, to make the initial incision. They just have to get used to something new.