During my surgical training, I shared in a perception that was common among OR professionals at that time: Sharps injuries were rare and unavoidable. We simply accepted them as part of the job. Now, three decades after my training, it's clear sharps injuries are common, unacceptable and within our power to prevent.
However, unlearning habits is far more difficult than establishing new ones. And modifying surgeons' behavior in the OR to include the use of safety devices is no exception. Here's what you can do to help your surgeons adapt.
Roadblocks to change
Three factors make changing surgeons' behavior especially difficult:
- Surgeons' preferences and work practices are established during training. For most surgeons practicing today, occupational safety wasn't an issue during residency. This changed when the risk of occupational infection with HIV, hepatitis C and hepatitis B became widely known, but many surgeons established habits before this risk was widespread.
- Most surgeons aren't facility employees and may not be included in educational programs on occupational safety that facilities provide for OR staff. Even if invited, full schedules leave surgeons little time for additional meetings.
- OR team members, especially junior staff, may be reluctant to initiate a discussion of safe work practices, such as no-hands passing, with surgeons. (Ironically, surgeons typically tell me they would prefer that OR staff remind them about safety issues.)
Help surgeons understand safety
How do you get surgeons to understand how non-traditional safety devices and safe work practices affect them and their patients? These facts will help you drive home that point.
- The Centers for Disease Control and Prevention estimates 125,000 percutaneous injuries (PIs) involving contaminated sharps occur in ORs annually.
- In 2000, the federal Needlestick Safety and Prevention Act became law. Enforced by OSHA, the law requires employers - including hospitals, ASCs and surgeons - to periodically evaluate and implement safety devices (such as blunt-tipped suture needles and safety scalpels) and safe work practices (such as a neutral zone for passing sharps).
- The Government Accounting Office found in 20001 that sharps safety devices save money, more than recouping their minimal additional cost by preventing extremely costly injuries.
- It's ethical to protect yourself from PIs and infection and, potentially, your patients from you. The risk of exposure to and infection with bloodborne pathogens is bi-directional: Patients have been infected after an injured infected surgeon bled into their incisions.
- The OR lags behind other healthcare settings in implementing safety devices. Between 1993 and 2001, the rates of PIs from most conventional (non-safety) sharp devices declined sharply, but there was only a minimal decrease in PIs caused by conventional suture needles (see "Little Change in OR Injury Rates").
My experience as a consultant has taught me that modifying your surgeons' behavior is best done using this step-by-step approach:
- Start at the top. You need administration's support. Ask your CEO or owner to verbalize his commitment to a safety culture in a memo sent to each physician's home.
- Identify your safety champions. Ideally, this is a surgeon who has successfully integrated blunt-tipped sutures and a neutral zone into his practice. The chief of surgery or another surgeon who would receive the chief's support is ideal. The champion can answer questions from your facility's utilizing surgeons.
- Assemble an OR safety committee. This multidisciplinary team should include your champion and representatives from OR staff, OR management, infection control/occupational health, risk management, epidemiology, materials management and administration. Review your sharps-injury log and analyze exposure patterns. The EPINet system (writeOutLink("www.med.virginia.edu",1)) is an excellent free tool for reporting and analyzing exposures.
- Educate peer-to-peer. Infection control and occupational health nurses often are responsible for worker safety education and training in the OR, but don't typically interact with the surgeons, creating a "credibility gap." Because of this, surgeons may exhibit pushback, responding with, "don't tell us how to practice." As a surgeon and educator, I know surgeons are most open to modifying dangerous behavior when one of our own clearly presents the benefits and methodology of change. This is where your champion is key.
- Set a timetable. Three factors to keep in mind here. First, implement key strategies one at a time, including no-hands passing of sharps (use of a neutral zone), blunt-tipped sutures, safety scalpels and effective personal protective equipment. Second, OSHA has fined facilities for less than full implementation of these safety measures, so document in an exposure-control plan each step of evaluation and implementation for each risk-reduction strategy. And third, periodically survey compliance by surgeons and conduct frequent hands-on inspections to troubleshoot and remind them to do the right thing.
Driving home the message
To modify behavior, reinforcement is key. Post attention-grabbing posters at scrub sinks and in the surgeons' lounge to reinforce safe behavior. Share data on in-house exposure rates quarterly to keep surgeons aware of the progress they've helped make - and the still-existing risks. With a little patience, and by following these guidelines, you can modify surgeons' safety-related behavior in the OR.
1. GAO-01-60R; "Occupational Safety Selected Cost and Benefit Implication of Needlestick Prevention for Hospitals." 17 Nov. 2000.