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Needlestick Safety Challenges Continue

By Tami Swartz  
   April 02, 2013

This article appears in the March 2013 issue of Patient Safety Monitor Journal.

Clinicians use needles, syringes, and related products every day to care for their patients. These devices carry inherent risk and, if not used and disposed of properly, pose a safety threat to clinicians, patients, and housekeeping, to name a few.

On November 6, 2000, the Needlestick Safety and Prevention Act was signed into law, and since then, there has been a significant decrease in sharps injuries. However, a coalition called Safe in Common is working hard to reinitiate safety efforts around sharps, believing that the healthcare environment has become complacent, and that even though sharps injuries have declined, consequences of injuries are still quite serious.

Safe in Common is a nonprofit dedicated to making the healthcare working environment safe from the risk of needlestick injury. It offers visitors the chance to take "the needlestick safety pledge," vowing "to support Safe in Common in its campaign to promote and strengthen the Federal Needlestick Safety and Prevention Act, raise awareness of needlestick safety, and utilize safer engineering controls to protect me and my fellow healthcare personnel from unnecessary needlestick injuries."

According to Safe in Common's website, 5.6 million healthcare personnel in the United States lack access to safety-engineered medical devices that can fully protect them from occupational exposure to bloodborne pathogens such as HIV and hepatitis C.

The Centers for Disease Control and Prevention, the ­Occupational Safety and Health Administration, the FDA, and state and federal legislation have all provided mandates and guidelines for sharps injury prevention in healthcare over the past 30 years. But according to expert Mary Foley, RN, PhD, former president of the American Nurses Association and current Safe in Common chair, although progress has been made, there are still problems to address.

"We recognize that there has been significant progress in safety, but we've also heard from nurses and students, housekeepers, patients, and visitors that they still have concerns for sharps safety and injury prevention," says Foley.

Safe in Common presented an online conference in November 2012 called "The Unfinished Agenda" to address the issue of sharps safety. The event featured live discussion as well as prerecorded interviews and videos with student nurses, key opinion leaders, and healthcare workers from across the United States. The event fielded more than 200 questions from healthcare workers from 15 countries. Although the panelists were able to weigh in on many of the questions, the majority are answered by the experts on Safe in Common's website.

Nearly 78% of the 1,000 who attended the online conference believe that needlestick injuries have not been eliminated in their workplaces. According to more than half of conference attendees (55%), the answer to protecting healthcare personnel from sharps injuries lies in safer engineering controls (i.e., safer medical devices). The other responses were "stronger enforcement of frontline worker input in device selection" (21.5%), "stronger OSHA enforcement of 2000 Needlestick Act" (12.9%), "Inclusion of healthcare worker injury rates in reimbursement metrics" (7.2%), and "standardized national reporting to a central database" (5.3%).

"I think we can safely say that the injury challenges of the '80s and '90s continue today, and the poll we conducted certainly confirms that," Foley said during the conference, adding that many of the safer needle devices used today were developed before the Needlestick Safety and Prevention Act in 2000.

"Innovation of and demand for safer products is stagnated," said Foley.

In addition to medical device enhancement, Foley said there are other areas in need of improvement that are more cultural and educational based.

"As Safe in Common has established in its first year, the issues of needlestick and sharps safety persist. There are serious concerns in the surgical arena, nonhospital settings, and in special populations," said Foley. "We have also heard that students are not adequately prepared to address their own safety when presented with equipment. They are not advised on why safety is an issue [and] how to use the equipment safely, and are discouraged from reporting injuries when they occur. That is unacceptable and demands a national response."

Foley also noted that although needlestick injuries cost hospitals money, victims of needlesticks often experience fear and anxiety about the possible consequences of an exposure. Victims can also lose time from work, or even become involved in litigation with the hospital.

According to a poll on Safe in Common's website, 42% of visitors believe that developing better injection devices is the most important action to take to help improve injection safety, while 35% believe greater awareness of the issue is most important.

Opportunity to combine worker, patient safety efforts
Sharps safety is also part of a larger discussion among healthcare leaders and professionals about what a culture of safety means, and whether it means combining all healthcare safety efforts, such as employee, environmental, and patient safety. Much of the time, the efforts for improvement are similar across all categories, requiring the same culture in the same care environment.

A recent Joint Commission monograph, Improving Patient and Worker Safety, released November 19, 2012, is intended to be an informational guide on how worker and patient safety correlate and can be integrated. It states that "a culture of safety-and the organization leaders who create and sustain it-will not be considered legitimate and genuine if the culture excludes some groups within the organization." The monograph urges hospitals to understand that adverse events and near misses that endanger one group of people at the hospital-for example, patients-often endanger another group, such as staff. Because the root cause is usually process- or communication-related, such problems are often culturally ingrained in the overall work environment and, therefore, are likely to affect and possibly endanger everyone.

Sharps safety is included in the monograph. In a table that explains how certain safety issues affect both healthcare workers and patients-Table 1-3: Topic ­Areas for Interventions to Improve Safety and Examples of Potential Benefits to Patients, Staff, and Organizations-the benefit of improving sharps safety to both patient and worker is a decreased exposure to bloodborne pathogens. The benefits to the healthcare organization include decreased workers' compensation claims and insurance costs, decreased litigation, and an improved safety culture.

"I would like to commend The Joint Commission for inclusion of provider safety in their monograph and call for greater focus in their accreditation and ­inspection process," said Foley. "Sharps containers and some other sharps-related items are included in the Environment of Care section [of the Comprehensive Accreditation Manual for Hospitals], but there has been inadequate attention paid to the culture of safety and device selection processes in the last few years."

Foley said the monograph should be only the beginning of a focus on worker safety.

"The focus on patient safety, including the National Patient Safety Goals, has contributed to efforts in leadership and staff to improve the quality of care. I would suggest The Joint Commission work closely with the occupational health community to identify national healthcare worker safety goals to guide a national conversation and guide healthcare leaders to attend to these priorities as well."

Needlestick prevention has typically been a topic for employee health professionals and those involved in the hospital's OSHA compliance efforts or human resources. Generally, the only ones using needles are staff, specifically clinicians. But as hospitals aim to become more patient-centric, with a cultural awareness of safety, many are beginning to realize the impact worker safety has on the overall healthcare environment, and patient safety in particular.

Often, hospitals find that staff who feel the hospital provides for their safety tend to provide safer care for patients. "If you have an employee injury and you have a patient injury, it really boils down to some of the same skill sets you need to address both," said ­Barbara Balik, RN, EdD, executive vice president for safety and quality systems at Allina Hospitals and Clinics, and an Institute for Healthcare Improvement (IHI) "frontline improver" in Profiles in Improvement: Barbara Balik of Allina Hospitals and Clinics (published by the IHI).

Balik used the example of patient falls to explain her point. A patient who has fallen might have done so as an employee tried to help the patient get up. Often, employees are hurt trying to catch a patient as he or she falls. Or, in the case of sharps, general unsafe practices are just as likely to result in a sloppy handoff that causes an employee needlestick as reuse of a syringe that leads to a patient contracting a bloodborne illness. The cause might be an underlying culture of apathy regarding the proper use of this medical equipment.

"Patient safety right now is getting all the attention, but we need to get worker safety higher up on the radar because many of these issues really are a combination of worker and patient safety issues-many of them overlap, and it's a logical connection," said Gina Pugliese, RN, MS, during the Safe in Common conference. Pugliese is vice president of Premier Safety Institute, adjunct faculty at the University of Illinois School of Public Health and Rush University College of Nursing, and senior associate editor of Infection Control and Hospital Epidemiology.

Pugliese noted the outbreak of infection from recent years that potentially exposed hundreds of thousands of patients to bloodborne pathogens, all from clinicians who followed unsafe injection practices, such as reuse of single-dose vials and syringes. "We know that patient safety culture and worker safety culture is linked," she said.

Pugliese said the same things that bring attention to and work for patient safety initiatives, such as visible support from management, also work for healthcare worker safety.

One example is the operating room (OR), which is infamous for being a difficult setting to implement patient safety processes such as timeouts, and is no less difficult in regard to employee safety topics like sharps. Forty-six percent of attendees said the OR represents their biggest challenge to sharps safety implementation.

Pugliese said methods that work for patient safety in the OR, such as physician champions, are usually most effective in occupational safety as well. She also noted how patient safety efforts could easily incorporate the topic of employee safety at the same time.

"We're seeing a lot of these patient safety walk-arounds, and it would be very easy to incorporate some of the worker safety issues into them," she said, ­suggesting hospital worker safety professionals ensure that the scripts often used for these walk-arounds address worker safety issues as well.

A culture of safety for both workers and patients also requires an environment that encourages reporting and is nonpunitive yet holds staff accountable. Pugliese suggested incorporating employee safety practices into performance reviews and credentialing procedures.

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