Reversing a Culture of Danger

Unreported sharps injuries shouldn’t be considered “part of the job” just to keep cases moving.

Aimee McFarlane, RN-BSN, CNOR, CST, suffered needlesticks twice — once as a nursing student and once after 12 years on the job.

One of the incidents occurred when a surgeon tossed a syringe onto the patient, which happened to be where one of her hands was, during a case with no established neutral zone to pass sharp instruments.

Alarming statistics

Ms. McFarlane knew there had to be a better prevention technique than constantly reminding herself to not place her hands on patients whenever possible. So she looked into the issue and was surprised to learn how many sharps injuries take place in operating rooms each year.

According to the International Safety Center’s 2023 EPINet Report for Needlestick and Sharp Object Injuries, 42.8 % of sharps injuries took place in ORs and recovery areas, more than any other location. Nearly 35% of the staff injured were nurses, more than any other provider.

“The stress that nurses experience is already high, and when they experience a sharps injury, nurses suffer from fear of exposure and this can lead to post-traumatic stress disorder (PTSD),” says Ms. McFarlane. “That’s why I helped to implement the Sharps Hazards Omitted Through Safety (SHOTS) program at the 24-OR acute-care facility where I used to work.”

• About the SHOTS program. The results from the program, which is still in its early stages, are promising. Neutral zones were established in nearly 70% of the 26 cases that were audited as part of the project during the first three months of 2023, the last time period for which data is available. A single sharp was in the neutral zone, the preferred practice, in nearly 58% of the cases.

Two needlesticks and two injuries from other sharp instruments took place during those problematic cases. The OR teams used a sterile towel as their neutral zone most often, while a mayo stand was the second most popular choice, says Ms. McFarlane.

The program emphasized the importance of creating a neutral zone, a designated place where syringes, suture needles, scalpels and other sharps are placed and retrieved rather than passing them hand-to-hand among team members.

The establishment of a neutral zone was added to preoperative time outs and an inventory to ensure all sharp instruments were secured and accounted for was added to the postoperative debriefing session.

“Calling attention to this issue in the time outs and debriefs is important, because these sorts of injuries take place in hectic environments while team members are recapping needles and performing other tasks,” says Ms. McFarlane. “Sharps injuries are also caused by a lack of education on how to prevent them, by staff not following training instructions or by having outdated policies and practices that need to be updated.”

Data was collected over six months using a rounding tool platform to audit information about how the ORs teams established and used the neutral zones. Collection occurred monthly and ORs were monitored quarterly after the original six-month period of collection.

• Training, communication and consistency. After the safe zone was created, training programs were created around the concept and messaging about the new initiative was communicated regularly. Ms. McFarlane got management on board early and then used two events each year — the facility’s safety fair and an annual sharps awareness event — to remind staff about how important the issue is. 

CDC’s ‘STOP STICKS’

A National Template to Tailor to Your Facility

The CDC’s Stop Sticks campaign is a great first step toward sharps safety. The campaign served as a guideline for the SHOTS program designed by Ms. McFarlane. It was originally created by the CDC’s National Institute for Occupational Safety and Health, but is now updated and maintained by the National Occupational Research Agenda (NORA) Healthcare and Social Assistance Sector Council.

Stop Sticks efforts can help raise awareness of the importance of sharps safety and, through various forms of communication interventions, can improve the knowledge, behaviors and attitudes of healthcare workers about the issue.

The campaign was designed to be implemented in its entirety or in part, depending on the needs and resources of facilities. It can be a standalone initiative or tied into others, such as the introduction of a new device or as part of annual training reminders about the hazards associated with exposures to blood and bodily fluids from a sharps injury.

Stop Sticks campaigns have four components: audience analysis, message development, message delivery and evaluation. It’s recommended that typical campaigns last about a month and be broken into weekly topics. For example, one week each could be dedicated to risk awareness, passing and loading practices, neutral zones and education about safer sharps devices such as retractable scalpels and blunt-tip suture needles.

Developers of the campaign emphasize that repetition is as crucial to getting your message across as the way you deliver it, so frequent newsletters, posters, paycheck stuffers, presentations, displays and promotional items are helpful.

“If you use this, I can virtually guarantee it will decrease your needlesticks, but it has to be a continuous program,” says Ms. McFarlane. “You need to be dedicated to it.”

The program also offers helpful information on how to gain the support of management in your efforts and how to evaluate the results of your program once it’s been implemented. For more information, visit osmag.net/stopsticks.

“This campaign gave us all the templates we needed,” says Ms. McFarlane. “We then integrated it into the specifics of the organization.”

—Adam Taylor

OR teams were instructed to note during the time out before a procedure that a neutral zone would be established and where its location would be. During procedures, it’s encouraged to verbally note what sharps are in the neutral zone and have the surgeon repeat it.

“Repeatedly saying where the sharps are, or that you are about to pass one, is a healthy habit,” says Ms. McFarlane. “Communicating by saying, ‘Hey, I have a blade in my hand’ can be all it takes to prevent an injury.”

Post-procedure debriefs include an inventory of sharps items. Doing this consistently could remind a nurse that a bovie tip is still on, which could prevent it from getting thrown away later and causing a downstream injury to a member of the environmental services or sterile processing staff.

How do you convince team members these measures are important when they’re already busy with 20 other things? “Explain that it’s a safety measure that can easily be incorporated into the normal workflow,” suggests Ms. McFarlane. “It’s like a period at the end of a sentence. The point is to get you to stop, because that’s the correct thing to do at that moment.”

Culture of safety

FIRST STEP The logical place to start when launching a sharps injury prevention project is to observe current practices.

Ms. McFarlane says she was shocked and in a state of disbelief after her most recent sharps injury. She scrubbed out and saw an occupational health nurse. The physical part of the assessment was more than adequate, she said.

“But there was no mental-emotional component, no follow-up to see how you’re doing,” she says. That’s certainly a gap in the process, as she notes that there can be real fallout from such an event. “There’s PTSD related to it,” she says.”If you get stuck once, you’re more likely to get stuck again. And it can lead to bigger issues, since worry and stress can lead to burnout and even nurses leaving the field.”

Surgeons often don’t report when they get stuck, preferring to keep working on the case and checking later to see if the patient has anything in their charts that might be concerning. “We’re so busy that we can get into the mindset of thinking that sharps injuries aren’t going to happen, even though we’re in hectic environments and around sharp instruments most of the time,” says Ms. McFarlane. “The thinking is that they’re part of the job, and we probably won’t contract anything.”

Ms. McFarlane recalls a time a nurse reported an injury saying the only reason she did so was because she was pregnant. “What does it say when we don’t value ourselves enough to protect us from injury? It’s sad,” she says.

She contends that if employees won’t remove themselves from a case immediately after a sharps injury, their workplace is essentially a culture of danger.

“You can’t say you’re part of a culture of safety if you won’t stop to help yourself when you get stuck,” says Ms. McFarlane. “People can’t work at their full capacity immediately after an incident like that. These things happen at the starts and ends of cases when we’re most distracted. If people don’t feel like they can take their time to be careful, that’s a problem.” OSM