One of our nurses was injured by a sharp during a procedure on an HIV-positive patient about 15 years ago. The injury didn't result in a bloodborne pathogen, but it did raise concern about sharps handling. To put a positive spin on a potentially negative situation, we developed rules for the handling of sharps devices, including their passing in the OR. Here's what we did, and how you can enhance sharps safety in your facility.

Creating a neutral zone
The most highly recommended technique for preventing sharps injuries in the OR is to create a neutral or safe zone for no-hands passing of all sharps. Here's how Outpatient Surgery Safety columnist Mark Davis, MD, FACOG, describes the steps:

• First, the OR team designates the safe zone. This could be a dedicated Mayo stand, mat, towel, needle magnet, basin, tray or designated area on the sterile field.
• Position the safe zone flat and level on the sterile field, within easy arm's reach of the surgeon.
• When the surgeon needs a sharps device, such as a hollow syringe needle, sharp trocar, suture needle or scalpel, the scrub tech should place it in the neutral zone, rather than passing it hand-to-hand.
• Finally, the surgeon picks up the sharp from the neutral zone.

To further reduce the potential for injury, says Dr. Davis, keep hands away from the neutral zone.

How we've modified the technique
One drawback to the neutral zone is that it can impede the procession of the case. Some of our surgeons objected to having to take their eyes off the operative site while retrieving the sharp from the neutral zone. To accommodate the physicians, we modified the procedure in the following manner.

• The surgeon orally requests the sharps device.
• The tech or nurse announces she will place the sharp in the surgeon's hand.
• The sharp is placed directly in the hand of the surgical team member who requested it. If the sharp is a suture needle, it is on a needle holder.
• When the sharp is returned, it must be on an instrument such as a needle holder, and is placed on a neutral zone predetermined by the surgical team members - whatever, within reason, facilitates the process.

If the procedure will require the patient to be in an odd position, such as the lateral position, creating the neutral zone can be a little more difficult. This is another area our flexibility comes in handy. It's perfectly acceptable for the surgical team to make a procedure-time decision about moving the neutral zone or further modifying our current process. But the OR staff must discuss it before the incision is made so that all members of the surgical team are on the same page about the procedure they'll be following throughout the case.

No facility has a best-practice model; sharps safety is always a work in progress. The key is to focus on communication, patient safety and staff safety when deciding what practices you'll use.

A boost for safe practice
Sharps devices manufactured specifically to reduce exposure to blades or needles can supplement safe techniques. Here are some safety sharps to consider for your facility.

• Disposable scalpels. These eliminate blade removal, a risky practice. Surgeons often don't like plastic disposable scalpels because of their light weight and smaller size, though they may be fine with them for quick, minor operations.
• Retracting and shielded scalpels. Passing with the blade retracted or shielded makes a modified no-hands technique safer. We're working on evaluating the newly introduced types of reusable handles with safety blades, which will give surgeons the heavier handles they prefer, OR management the cost savings it wants and everyone the safety they desire.
• Bladeless trocars. Eliminating the sharp aspect makes them safer, but surgeons might find they can slip during a procedure.
• Safety syringes. If you must recap a syringe to pass it, use the one-handed technique. Better yet is to pass a capped syringe whose needle can be retracted after use.
• Blunt-tipped suture needles. These are intended to sew non-skin areas, bowel, viscera and other soft tissue. Manufacturers made the integrity of the tips less sharp so they'd pierce these tissues and not skin. But when it comes to sewing skin, you still have to have a sharp needle - which is sharp enough to stick the operator. Surgeons balked at first-generation blunt-tipped suture needles because they had to change their techniques. There have been some changes, and you can choose among varying degrees of bluntness, which may help you introduce surgeons to them. Use a needle holder to pass regular or blunted suture needles.

Behavior reinforcement
Even if you have a good policy in place, you need to also have the courage to follow through. Safe practices are expected in our facility (see "Who Wants to Be a Safe Surgeon?"), but when there is a lapse in behavior, staff are expected to report it to their manager, who'll take it to our professional conduct committee if needed.

The committee is comprised of physicians, including surgeons, who will review the incident from a purely concrete angle: What was the impact on employees, patients and peers?

Preferably, staff will speak up when something negative happens. We've noticed a generational difference here; Baby Boomers have a tendency to wait to report, while Generation X and Y employees often have no problem saying, "That wasn't safe, and I'm not going to tolerate it in this OR." It's also a matter of where you are in the hierarchy; RNs are more willing to speak up than scrub assistants. Sometimes, it's a function of how long you've worked with a given team. If you've developed a good working relationship, you might not want to be adversarial. Other times, it's just a personality thing; some people are more timid than others.

We've empowered everyone to speak up, but we recognize they might want to go about it differently. Having the professional conduct committee has removed some of the potentially adversarial components of pointing out unsafe practices. An important and further-empowering aspect of our policy is that retaliation is a second offense.

A matter of time
It's important to underscore the importance of standardized operative procedures. The OR is extremely intense and fast-paced. If you have everybody expecting to perform safety-related tasks in the same manner, procedures are much more likely to move along quickly - and more safely.