Overcoming Barriers of Safe Sharps Handling

Just because a surgical team uses safety-enabled scalpels and suture needles doesn’t mean everyone is safe from getting stuck. “Safety-engineered scalpels are meant to protect people during passing of the instrument, not during use,” says Gail Horvath, MSN, RN, CNOR, CRCST, patient safety analyst and consultant of patient safety risk and quality at ECRI, a nonprofit organization in Plymouth Meeting, Pa., that focuses on safe, effective and efficient health care. “They prevent sharps injuries when a scrub tech or nurse passes the instrument to the surgeon. Once it’s unsheathed, they’re as sharp as any other blade.”

Julie Miller, MS, senior project officer of ECRI’s Device Evaluation Group, says safety sharps often aren’t consistently or properly used. “When safety-engineered sharps are in use, there’s nothing to prevent an accident from happening,” she says.

Safety scalpels have either an extendable sheath that the provider activates with their thumb by pushing it forward, so it covers the blade when it’s not in use, or a box cutter-like mechanism that retracts the blade back into the handle. These extra steps are considered time-wasters by some providers. “It’s the requirement to use this active feature that has a lot of people not using them,” says Ms. Miller. “There is a perception that these devices take too long to activate, so that was part of our testing, a simple task — pick up the scalpel, activate it if you need to make some cuts and recover it and put it back down.” She calls the time involved in that task “negligible.”

In addition, many surgeons continue to avoid safety-engineered blades for “feel” reasons. “They think they wouldn’t feel like a standard reusable scalpel with a metal handle that they’re used to,” says Ms. Miller, who suggests facilities and surgeons take a fresh look at these devices and their improvements over time.

“Our first evaluation was back in 2002, and there have been some developments since then,” says Ms. Miller. “Manufacturers have bulked up the handles, so they feel a little bit sturdier, more like what surgeons are used to.” She notes that most ORs employ reusable handles with disposable blades.

Just as dangerous as scalpels are suture needles, the safety-engineered version of which requires some clinical concessions. “With safety-engineered suture needles, the only engineering controls out there are blunt needles or reverse-cutting needles,” says Ms. Horvath. “Blunt suture needles have not gained much traction because they’re very difficult to work with. They don’t penetrate muscle very well, they’re not as gentle on tissue because it’s more like it’s tear into it, and it requires require more force from the operator.”

• Alternative methods. One way to reduce sharps injuries is to use fewer sharps. “Other things are being used in situations where scalpels and needles have been used,” says Ms. Horvath. “For example, electrosurgery — surgeons are increasingly using cautery to dissect and create initial openings, and they’re not going to get cut with that.”

Ms. Horvath points out another example surrounding colon resection. “You would traditionally do your anastomosis with a suture, but now they’re using endomechanical devices and staples,” she says. In terms of closing, she notes that many providers are moving away from suture needles completely to either staples or skin adhesives.

• Double-gloving. This is proven strategy for mitigating and preventing sharps injuries where, if the top glove is torn or stuck, the provider will see the different color glove underneath and immediately address the breach. Ms. Horvath notes that double-gloving is a recommended practice by both the American College of Surgeons and AORN, but some specialties embrace it more than others. “You’ll find very few orthopedic surgeons who do not double-glove, but you might find people who perform very delicate surgeries such as plastics, neuro or ophthalmic, who do not like to double-glove because of decreased tactile sensation,” says Ms. Horvath.

• Competency-based training. Standard training on sharps safety is important, but it’s truly the least you can do on its own. “Education is really a low-impact strategy,” says Ms. Horvath. “There needs to be monitoring and reinforcement and consequences in a just-culture algorithm.” Staff — surgeons and OR staff alike — need to be held accountable for doing the right things, and you can do this by including sharps safety in your annual competencies and bloodborne pathogen training, adds Ms. Horvath.

• Behavioral modification. Minimizing distractions in the OR is one way to keep surgeons and staff more focused when handling sharps, which can be encouraged and extended by reinforcing good behavior, says Ms. Horvath. “The worst sharps injury I ever saw was when a surgeon put a Hemovac trocar — a large drain — through the muscle and right through the senior resident’s hand, impaling him,” says Ms. Horvath. “It occurred at the end of a case, and the surgeon wasn’t aware the resident was still cleaning out the wound.”

You also need to account for provider fatigue. Ms. Horvath says her only sharps injury in the OR came at the end of a 16-hour shift at a hospital. While such shifts don’t normally occur at outpatient facilities, it’s worth keeping an eye on how surgeons and staff handle sharps at 8 a.m. and compare it with how they do so at 4 p.m., after a long day of surgeries and patient care.

• Reporting and analyzing injuries. Root cause analyses (RCA) of sharps injuries aren’t performed nearly enough, according to Ms. Horvath. “Aggregate all your sharps injuries and do a true RCA,” she says. “You might be surprised what you learn, and then be able to create a really effective action plan you can put into place to prevent these injuries.” Of course, to address sharps injury issues, you need to know they are occurring. Ms. Horvath says many of these injuries not only go unreported to OSHA, but even to administrators at the facility. Adds Ms. Miller, “You often hear, ‘It’s never happened to me or anybody I know,’ but maybe they just didn’t tell you about it. Increasing surveillance can help quality improvement in terms of sharps safety.”

Why are OR staff and surgeons not telling their superiors about these injuries? “I assume they think nothing of it half the time,” says Ms. Horvath, who notes time pressures and a reluctance to enter an episode of care in an ER play a role in the silence. “If the protocol says you need to go to the ER, you’re going to sit in the ER for three hours before they get a chance to get around to you.”

• Workplace culture. One tough question every surgical leader should ask about sharps safety: Does management hold surgeons accountable to use safety-engineered devices and adhere to other sharps-related policies and protocols? 

“I find that facilities where surgeons are not employees are more likely to cater to what the surgeon wants than organizations with an employed surgical staff that can hold them to certain behaviors and limit what they can and can’t use,” says Ms. Horvath.

Ultimately, sharps safety requires awareness, consideration and action — even if you’ve never had an injury at your facility because, as Ms. Horvath puts it, “Something that’s never happened before happens every single day. Tomorrow might be your turn.” OSM