A recent citation by the Occupational Safety and Health Administration (OSHA) shows that facilities that are in the process of converting to safety devices, and have made substantial progress in doing so, are still subject to fines for using conventional devices when safety alternatives are available.

Violations cited
OSHA's citation, issued Sept. 30, fined Montefiore Medical Center (MMC) in New York City $9,000 for three serious violations of the bloodborne pathogens standard (BPS):

• failure to use engineering controls (with 26 specific instances listed where safety-engineered devices were not used)
• improper handling of contaminated reusable sharps; and
• failure to make available, or ensure that employees used, personal protective equipment.

OSHA deems a violation serious when there is "substantial probability" death or serious physical harm could result from the cited condition, and the employer knew, or should have known, of the hazard.

Five violations categorized as "other than serious" were also cited, all having to do with recordkeeping or documentation required by OSHA:

• one related to the OSHA 300 log;
• three to the exposure-control plan required by the BPS (failure to review and update the plan to reflect evaluation and implementation of safety devices) and
• one related to the sharps-injury log (with six specific instances cited of improper or incomplete documentation).

Though Montefiore has implemented safety devices in some categories and for some procedures, OSHA's citation made it clear that safety devices were not being used across the board in all clinical areas. Montefiore has two teaching facilities - MMC/Moses Division and Weiler Hospital at the Albert Einstein College of Medicine - with a total of 1,126 beds; both facilities were included in the citations.

Not enough
Stephen Cha, MD, MMC's chief medical resident and one of a group of residents who filed the complaint, observes: "In terms of implementing safety, Montefiore is probably pretty typical of many large teaching hospitals - it's done a fairly good job with safety. But I think the message here is that 'pretty good' is not good enough."

Dr. Cha, who has worked at MMC since 1999, says that in the complaint the residents tried to focus on devices that are used every day, throughout the hospital and for common procedures. "We also tried to give OSHA as much detail as possible on how and where non-safety devices are used," he says. The most problematic areas, according to the complaint, were surgery, the intensive care/critical care units and the emergency department. The complaint also noted that sharps injuries had increased in the previous two years - by 5 percent in 2001 and by 7.3 percent in 2002.

Residents take action
Shortly after OSHA issued the citation, Dr. Cha, the other Montefiore residents and the president of the American Medical Students Association wrote a letter, together with the consumer advocacy group Public Citizen, to the American Hospital Association (AHA). The letter urged that the AHA notify member hospitals about OSHA's action. "Because we believe that conditions similar to those at Montefiore likely exist at most hospitals in the U.S.," the letter states, "many AHA members currently risk OSHA sanctions [and] ' nurses, residents, medical students and other hospital staff are placed at unnecessary risk of acquiring potentially fatal infections due to needlestick injuries." The letter asked the AHA to facilitate "compliance of your member institutions with current OSHA standards" by alerting them to "this landmark OSHA ruling." And it warned that, "in the alternative, medical students and residents stand ready to file institution-by-institution complaints against violating hospitals."

This last statement - threatening to carry out similar actions in hospitals across the country - if acted upon is particularly significant, as it would mark the first time a group of physicians took national-level action against healthcare facilities to bring about compliance with the BPS. "We hope that hospitals across the country take heed of what happened here at Montefiore and work harder toward the goal of full conversion to safety-engineered devices," says Dr. Cha.

In response to the residents' letter, the AHA says it has actively supported needlestick-prevention initiatives, including the federal Needlestick Safety and Prevention Act, and has sent out "multiple advisories on the topic [of sharps injury prevention] to hospitals across the country." It did not indicate it would take further action in response to the letter.

A lesson for all
Despite widespread conversion to safety devices in the United States, market data indicate the process is not yet complete. Some clinical areas, such as anesthesia and surgery, have been particularly slow to convert to safety devices.

The Montefiore citation shows that healthcare facilities need to aim for full compliance with OSHA's requirement to use safety devices to reduce the risk of sharps injuries. The citation also highlights the need to continually update the facility's exposure-control plan and needlestick-prevention program, and to monitor the use of safety devices and personal protective equipment - not just what is stocked - in all clinical areas.