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Speak Up to Prevent Sharps Injuries
Mark Davis
Publish Date: October 10, 2007   |  Tags:   Staff Safety

Mark S. Davis, MD, FACOGOR workers have to mentally multitask when sharps are in use, focusing simultaneously on patient and worker safety. The human tendency is to devise a pecking order, and most often, patient safety comes first. Even if there is unexpected bleeding during a procedure, and speed becomes a factor, patient safety is still at the fore, right? This is by no means wrong - it's just that you must give worker safety nearly as much attention.

But thinking about worker safety does little good if you're not talking about it as well. You can help prevent needlesticks and subsequent exposure to bloodborne pathogens by teaching OR team members at all levels of responsibility to identify obstacles to communication and overcome them. Here's how.

Mark S. Davis, MD, FACOG\ Don't fly blind
Preventing injuries starts with being observant - and not just in the healthcare setting.

We can look to the aviation industry for guidance in promoting quality and improving performance in our use of sharps. Aviators learn by analyzing deviations from expected or desired results. After an airplane crashes, Federal Aviation Administration investigators look for the cockpit recorder (the black box) to try to find out what went wrong and what could be done in the future to avoid a similar mishap. What many people don't know is that every time a commercial airline pilot executes a series of maneuvers, and the result varies from what was expected (example: air traffic control asked the pilot to ascend 10,000 feet but the aircraft only ascended 8,000 feet), the pilot is required to communicate with NASA personnel before and after landing. They replay the sequence of maneuvers to see whether protocol wasn't followed, an instrument malfunctioned or both.

We should apply to the OR the proactive approach to risk management used in aviation. For example, consider the common scenario of a suture needle or scalpel injury. Communication after every incident should include two questions:

  • Could we have substituted a safer device (such as a blunt needle or safety scalpel)?
  • Could we have avoided manual handling of the sharp or manual retraction?

If the answer to either question is yes, you can appropriately alter protocols regarding device selection and work practices to prevent future injuries. Once you have protocols in place, the next step is to enforce them verbally.

Recognizing and Verbalizing Risk

Here are examples of recurring injury and exposure scenarios you've likely observed during sharps use in the OR. Some are derived from my own experience, some were learned the hard way and others come from stories audience members have told during my presentations to surgeons and OR staff. Next to each scenario, I offer an appropriate verbal response that any member of the surgical team can use - for everyone's protection. These examples may seem simplistic, but the truth is that simply verbalizing risk is too often not done.

- Mark S. Davis, MD, FACOG


Appropriate Verbal Response

A member of the surgical team enters the OR without her usual eye protection.

Any team member: "Excuse me, I think you forgot your eye protection."

A surgeon is about to tie a suture, but the needle hasn't been removed.

Assistant or scrub: "Excuse me, may I cut that needle off before you tie?"

A suture is required. Manual retraction by a team member is in use.

Any team member: "May we replace this hand with a retractor?"

A visible color change (blood or indicator) is seen under the surgeon's outer glove, or there is a visible hole or tear in someone's glove.

Any team member: "Excuse me, I think you need to change that glove."

A sharp is observed lying on the field, outside of the no-hands-passing zone (neutral zone).

Scrub person: "I'll get that sharp off the field." (That way, two people don't reach for it simultaneously.)

Obstacles to communication
Communication should be spontaneous, regardless of the level of responsibility of the OR team member. A newly graduated nurse or scrub technologist might not verbalize a perceived risk because of reluctance to question the actions of another, possibly more senior member of the surgical team, especially the surgeon.

Taking another lesson from aviation risk management, flight-deck protocol requires that any member of the flight crew who perceives an actual or potential error bring it to the attention of the pilot. It's accepted that the judgment or opinion of the pilot can, and in fact should, be questioned. Commercial pilots tell their crews, "It's not a mistake until we both make it." By building redundancy - the awareness of multiple observers - into the system, you prevent adverse events make the system safer.

In the OR, where the surgeon is the pilot, the same approach can and should apply. For everyone's protection, you should fully utilize all human resources to prevent adverse events.

The liability crisis in healthcare has been a major obstacle to communication, and to performance improvement. Accountability for errors and mishaps is essential to improvement, but a culture of guilt, blame and punishment does not foster discussion and analysis of adverse events and near misses.

Safety pays
Need further motivation? Making the surgical environment safe for patients and workers saves money. The Government Accountability Office recently reported that sharps safety devices more than pay for themselves by preventing costly injuries and exposures. Putting in your two cents is a valuable risk management tool that can also potentially save you thousands.