It appears we may have reached something of a plateau when it comes to safety in the nation's ORs: We have the tools, but we've yet to really embrace them. That's where creating a culture of safety comes in, and this task is the responsibility of the OR manager, the director of surgical services and members of a facility's administration. Here's what you need to know to manage the environment to prevent sharps exposures.

Seven pillars of a culture of safety
First of all, you need to know the components of a culture of safety. Here are seven key factors.

• Individual responsibility. Perhaps the most effective way to drive home the importance of safety is to stress this message to your employees: Only you can know how a sharps injury can affect your life.
• Joint accountability. Anyone who is not part of the solution is part of the problem. Period. Old habits and denial only put the rest of the surgical team (and the patient) at risk, so everyone should have a vested interest - and be expected to have a hand - in curbing unsafe behaviors.
• Initiative. As more employees in your facility adopt safer techniques and technology, the position of the minority who resist will become untenable.
• Innovation. Gather data and product literature on all the tools available for increasing safety in the OR. These aren't your first-generation models. Blunt-tipped suture needles are more user-friendly than ever before. Safety scalpels continue to improve as manufacturers receive input from surgeons.
• Respect for diverse safe approaches. All members of the surgical team must understand and accept the simple truth that the solution to exposures is changing how they do things, from using blunt-tipped suture needles to adopting no-hands passing zones.
• Collaboration. Take into account the needs of your staff when buying personal protective equipment and safety devices. Encourage staff to voice their needs and to assume a share of the responsibility for their own protection. If a specific item doesn't meet the needs of all staff, explore additional or alternative equipment.
• Continual improvement. Failing to monitor any program after implementation shows staff that you're not serious, and all but dooms any changes you have made. To prevent this, hold in-services and training sessions regularly; monitor the daily use of personal protective equipment, safety devices and safety protocols; document exposures; and use the exposures data to measure the effectiveness of the steps you've taken. Don't be afraid to re-tool in areas where you don't see safety gains.

I also recommend that the surgical leadership meet and develop a mission statement. Perhaps something like this: "Our goal is to provide a safe, functional and effective surgical environment for patients and staff."

Deal with doubters
Old habits, denial and other negative factors that lead to dangerous behavior patterns will almost always yield in the face of persistent factual information. Luckily, there's lots of it out there to bolster your case for safety. Here are a few resources I've found effective:

• in-services and workshops held by reps and in-house and outside experts;
• small group discussions;
• periodic communication and updates on bloodborne pathogen risk in the form of posters, memos, flyers, newsletters and videotapes;
• mentoring of new personnel by experienced staff;
• safety checklists posted in each room to remind staff about personal protective equipment, work practice controls, and sharps management and disposal devices; and
• easy access to support and advice.

For optimal results, I suggest you identify a safety champion. This could be either an outside consultant or a known and respected local leader (or both). The safety champion is someone who speaks out to facilitate implementation of safer sharps devices and safer work practices. This is especially important in obtaining buy-in to the project from surgeons and physicians who aren't employees or shareholders of the facility.

Appealing to surgeons
Once you've identified the leaders, will their message resonate enough to effectively capture the imagination of the doctors?

I recently came across a powerful tool used by one safety champion at a large hospital network where I am involved in an ongoing consulting project. I give presentations to help implement safe best practices to protect personnel at their surgical facilities. While attendance by OR staff is typically excellent, surgeon attendance at the start of the project varied considerably. Everyone knows how busy surgeons are and how difficult it can be to get them all in the same room for a meeting.

But at one large hospital I visited last year, I was struck by the excellent level of surgeon attendance. In fact, the large auditorium was packed to standing-room only. Not only were almost all the surgeons present, but emergency department, anesthesia, radiology and family practice physicians attended as well. Just before he introduced me as the speaker, I remarked on how pleased I was to see so many surgeons and physicians in the audience. He smiled knowingly as he explained, "They all received a letter, mailed to their home address - from someone they respect."

After my presentation, I asked to see a copy of the letter (see "A Message From the Heart"). We now use it routinely to ensure good attendance.

Your task
There's no doubt surgical safety has made great strides the past 20 years. We now have access to the safer technology OR workers have long needed, and we have the tools to communicate and educate. It's up to you to do the rest. You can't build a culture of safety overnight. Pick and choose the recommendations that will work for you as you take it one step at a time.