Plastic surgeon Richard T. Vagley, MD, describes himself as fussy. Obsessive-compulsive. And incredibly meticulous. He's tried a safety scalpel. Once. Didn't like it, and probably won't try one again. For whom? For what?

"It didn't feel comfortable in my hand. It's just like a baseball player who's used to swinging a 34-ounce bat picking up a 32-ounce bat," says Dr. Vagley, the medical director of the Pittsburgh Institute of Plastic Surgery. "I'm an old dog. I'm accustomed to using what I've been using for some years."

Surgeons like Dr. Vagley tend to be mavericks, but when it comes to a surgical case and the performance of each task within the surgical procedure, surgeons are creatures of habit. They like a certain suture, a particular needle, a specific retractor. So you'd better have a good reason to ask them to abandon their tried-and-true scalpel for a retracting- or shielded-blade model that feels different, looks different and cuts differently. A better answer than, "it's all in the name of sharps safety and needlestick prevention." This article will give you a few good reasons, as well as update you on the slow but steady progress surgical facilities have made converting to safety sharps and reducing needlesticks.

Changing surgeons' ways
The hard part: Getting surgeons to change their routines - something they'll typically do only after a long trial, testing and general consensus. What not to do? Lay down new laws in e-mails or memos to surgeons. This will surely backfire, as will threats of such punishments as docking pay or rescinding parking privileges, says surgeon and sharps safety proponent Martin Makary, MD, MPH.

"It's sort of like raising a child: Positive reinforcement is a lot better than negative feedback or punishments," says Dr. Makary, of Johns Hopkins.

Here are six quick strategies you might consider.

1. Send in the clones. Identify a physician champion to tout safety devices. "We surgeons only relate to other surgeons," says Dr. Makary. "Sending in others to tell us what to do can not only be ineffective, but also it can alienate the very people you're trying to reach."

Preferably, your safety champion should be the chief of surgery or the surgical manager, says Jane Perry, MA, the director of communications at the International Healthcare Worker Safety Center at the University of Virginia Health System. "Getting compliance with implementing safer devices and practices is much easier and meets with less resistance if staff perceive a safety initiative as coming from inside, rather than imposed from without," she says. Also, if possible, try to find a similar champion among anesthesiologists, adds Ms. Perry.

2. Tell surgeons their options. Surgeons need to understand the options and alternatives available to them. For example, blunt suture needles are available in degrees of bluntness, some of which are almost as sharp as regular (sharp-tip) suture needles. And more of today's safety scalpels are disposable and have heavier handles, as manufacturers try to mimic traditional devices, notes Robyn Silverman, a senior project officer for ECRI, who has evaluated more than 90 safety-sharp devices in the last seven years.

There's more. Surgeons can use tissue adhesives and surgical staples for skin closure. Do surgeons know about such alternative cutting methods as blunt electrocautery devices and laser devices? What about the no-hands-passing (or neutral zone) technique employed for passing instruments?

"Get safety on the agenda at surgical staff meetings and share surgical sharps injury and exposure data," says Ms. Perry. "Show data by device type, occupational category and mechanism of exposure."

3. Give them plenty to choose from. You'll experience a higher level of success if clinicians have more options, says Lori Robertson, RN, CNOR, the assistant director for perioperative services at Rockingham Memorial Hospital in Harrisonburg, Va. If a GPO limits your options for vendor choice, find ways to work around this issue when approaching safety devices. Find a product that will sell itself in terms of ease of use, says anesthesiologist Adam F. Dorin, MD, MBA, the medical director of the Grossmont Plaza Surgery Center in La Mesa, Calif. "We all have had experience with products that make, for instance, placing an IV harder and thus, potentially, more dangerous than a traditional non-needleless system," he says. "Find a good product and run with it."

4. Deal in dollars. Showing the cost of dirty needlesticks or scalpels has a real impact, says Geoffrey Hibbert, RN, director of nursing at the Center for Special Surgery in Greenville, S.C. His strategy: Show surgeons what a patient or nurse who contracted hepatitis or HIV because of a needlestick injury would do to insurance premiums. "The costs can become astronomical," he says. "Show them in the long run what you could do as far as avoiding that liability."

5. Report needlestick injuries. A CDC survey found that the average underreporting rate of needlestick injuries at hospitals is 57 percent. The underreporting rate for surgeons is believed to be higher than that. "If surgeons know that sharps injuries will be reported, they'll be more likely to comply with implementing safer devices and practices," says Ms. Perry. "They don't want to report every needlestick they get. That involves follow-up bloodwork."

6. Know that the law's on your side. You probably know that the Needlestick Safety and Prevention Act of 2000 and the 2001 revised Bloodborne Pathogens Standard require healthcare facilities to maintain a sharps injury log. The log must include, at a minimum, the type and brand of device involved in the exposure incident, the department where the exposure occurred and an explanation of how it occurred. But did you also know that the law requires employers to conduct their own evaluations of available safety devices? In other words, your facility must select devices to evaluate based on a consideration of its own needs and requirements.

A nurse manager who wishes to remain unidentified shares this episode. Until OSHA came into her center unannounced, her physician-owners didn't realize how serious it is to not comply with sharps safety laws. "I said to one surgeon jokingly during the inspection ?Don't worry, it will only be a $100,000 fine.' He responded completely seriously, ?They can fine us?' After that experience, there has been much more respect for the laws and interest in compliance with the sharps laws," she says.

OSHA technically couldn't cite surgeons and anesthesiologists who aren't hospital or ASC employees for not using safety devices, but it could cite your facility for not providing a safe environment for nurses, techs and other employees, says Gina Pugliese, RN, MS, vice president of the Premier Safety Institute.

Safety sutures sluggish
In some sharp medical device categories, such as safety butterfly needles and IV catheters, the conversion to safety devices is near complete, according to market data from medical device companies. But surgeons have been exceedingly resistant to use blunt tip sutures - despite evidence that sharp-tip suture needles are responsible for the largest proportion of sharps injuries in surgical settings. Some market data:

• Safety butterfly needles. In 2003, 96 percent of hospitals used them, compared with 84 percent in 2001. In 2003, 75 percent of alternate sites used them, compared with 52 percent in 2001.
• IV catheters. In 2003, 92 percent of hospitals used them, compared with 78 percent in 2001. In 2003, 78 percent of alternate sites used them, compared with 62 in 2001.
• Sutures. Sharp-tip sutures had the same 97 percent market share in 2003 as they had in 2001, leaving blunt sutures (curved suture needles that have a relatively blunt tip) as the last untapped safety device. Blunt tip suture needles are safe before, during and after use - unlike most other safety sharps that won't eliminate injuries during use and require you to activate a safety mechanism before use (such as a retractable scalpel blade) or after use (such as a sheathed needle).

"It's possible to eliminate suture sharps - not completely, but drastically," says Ms. Perry. "Either surgeons aren't aware of the way they can be used as safety devices or they're not aware that they're appropriate for suturing internal tissue in most cases."

Some say the very trait that makes blunt sutures less likely to cause percutaneous injuries - they don't easily penetrate skin - is hindering their acceptance as a safety device. Blunt suture needles require considerably more pressure to penetrate tissue than conventional curved suture needles do.

Sutures are the No. 1 cause of sharps injuries in surgical settings, causing more than half (51 percent) of them. Of injuries sustained by surgeons while in contact with the operative site, 71 percent were caused by sharp suture needles, according to a study by the Exposure Prevention Information Network - known as EPINet - a data collection program of the International Health Care Worker Safety Center conducted with AORN. The study also found that sharp suture needles caused 40 percent of surgical nurses' injuries.

Help may be on the way. The American College of Surgeons in October endorsed the universal adoption of blunt suture needles as "the first choice for fascial suturing to minimize or eliminate needle-stick injuries from suture needles." The Statement on Blunt Suture Needles addresses the need for methods of reducing the rate of cuts and needle-stick injuries that occur during operations. This statement explains that cuts and needle-stick injuries happen in about one to 15 percent of all operations, with the most common cause of suture needle injury being the suturing of fascia, during which 59 percent of all suture needle injuries occur.

Ms. Perry suggests you use the ACS statement to persuade surgeons to switch to blunt suture needles for routine practice. Safety proponents will submit a request to the FDA to issue a safety alert on sharp-tip suture needles, says a source.

Why would a surgeon use blunt suture needles other than to protect himself? There are clinical reasons, too. For example, a description of the Ethiguard needle says, "The Blunt Point needle can be used to dissect through friable [fragile] tissue rather than piercing it. This needle has a round body with a rounded blunt point that will not cut through tissue. It has application in blunt dissection and for suturing of friable tissue, such as liver, kidney and spleen. As these tissues are highly vascular, a taper point would traumatize the numerous blood vessels, causing excessive bleeding, whereas a blunt needle can dissect between them."

Culture of safety
A focused initiative such as needlestick prevention should be preceded by culture change in order to be successful, according to ECRI's November 2005 report, "Culture of Safety." The report says that a culture of safety is necessary before you introduce other patient safety practices. Otherwise, individuals expected to implement the safety initiatives don't yet know how best to work together or how to communicate most effectively. An atmosphere in which healthcare workers can report actual or potential errors, events and hazards without fear of reprisal is the hallmark of a nonpunitive environment and is consistent with the open communication necessary for a culture of safety. (See "Building a Culture of Safety" on page 68.)