Most sharps injuries occur during the passing of instruments. But let's be honest: Some set-in-their-way surgeons think the neutral field is an unneeded extra precaution for the rare possibility of a sharps injury — something that wouldn't happen to them. Here are some pointers for re-emphasizing a designated neutral zone, a vital but sometimes ignored aspect of surgical safety.

1. Shout it out. The responsibility to establish a neutral field often lies with the scrub tech. She should, at the start of each case, assertively announce its location. Here it is. No ifs, ands or buts. That surgeon who doesn't want to work with a neutral field? Even he can't operate without the tools of his trade. Place his instruments in the neutral field. If he wants to keep working, he'll reach there. How else will he operate?

2. Define it. Identifying the surface of the neutral field is just as important as letting the surgeon know that it will be used. A folded towel works. So does a Mayo tray. Also consider using one of the many commercially available products. We trialed many of these products, finally settling on an orange plastic container that sits atop an orange no-slip mat (see photo on facing page). Some techs forgo the tray to place instruments on the no-slip mat. That works, too. Whichever they use, we've heard that staff like the bright orange color of the tray and mat, a hue they say serves as a visual reminder of the neutral field's location during surgery.

The commercially available options are single-use and similar in price — figure on spending $5 or less per case. Conduct trials to determine your staff's preference, but keep in mind that the tray should be adequate enough to hold the largest sharp in your facility. A no-slip mat or similar anchoring device is also a good design feature to consider; a neutral field is useless if the slightest bump sends instruments crashing to the floor. Some neutral field trays are magnetized to keep instruments securely in place. That is a neat concept, but have you ever tried to guide a magnetized needle in a tight surgical cavity? Not good. Keep in mind that instruments placed in a magnetic field may eventually need to be demagnetized.

3. Speak up. Verbal communication is essential in making the neutral field a success. That verbal communication begins with the announcement of the field at the start of each case. It continues throughout the procedure as each instrument is placed on the towel or tray. The passer needs to alert the receiver that an instrument is on the field. Be simple. Be direct. Saying "knife" or "sharp down" when placing a scalpel lets the surgeon or tech know that an instrument is ready for transfer, while also alerting them to what they'll be grabbing for. Surgeons are, understandably, so focused on the surgical site that they often don't look at the neutral field as they're placing a scalpel or suture. A verbal cue serves to coordinate the hand movements of the surgeon and tech, alerting the other to keep his hands clear of the sterile field while a pass is in progress.

Talking amongst surgeons and techs is particularly important during microscopic surgery, when employing a neutral field is near impossible because surgeons rarely look away from the surgical scope. Ophthalmologists and neurosurgeons, for example, often pass instruments directly to techs out of necessity. Clear verbal communication in these specialties is of particular importance.

4. Take the extra step. Several of our younger surgeons have begun to clip the suture needle holder over the sharp end of suture needles before passing used needles back to the techs. Yes, it takes a few seconds to cover the needle, but that simple step has eliminated the possibility that our techs will injure themselves. A little effort by the surgeons goes a long, long way.

5. Educate, educate and educate some more. Staff education is sometimes a clich??, but that doesn't mean your clinical team wouldn't be well served with a reminder about sharps safety. Talk to them about the consequences, both emotional and financial, of endangering patients and themselves with the careless handling of instruments. Testing patients or staff for HIV, Hepatitis B and Hepatitis C can be expensive, both financially and emotionally. If you see room for improvement in your staff's handling of sharps, measure their baseline compliance in using a neutral field and track their future performance for comparison. Present that black-and-white proof at your weekly staff meetings. Emphasize the improvements you want to see in staff compliance and reward surgeons and techs when they reach those goals.

Give yourself a break
Remember, not all sharps injuries occur during the passing of instruments. Scalpels and suture needles are no less sharp after a case has ended so staff must be vigilant when clearing the surgical field of instruments. Perhaps the easiest reminder is sometimes the most difficult to implement: tell staff to slow down when handling sharps. Speed and efficiency matter in ambulatory surgery, but not more than the safety of your staff and patients.