Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program

Contents:

OPERATIONAL PROCESSES

Implement Procedures for Reporting and Examining  Sharps Injuries and Injury Hazards

Introduction

Most healthcare organizations have procedures to report and document employees' exposures to blood and body fluids. However, many organizations have or are initiating procedures to identify hazards or near misses that could lead to sharps injuries and other adverse events. The latter is a proactive way to intervene to prevent injuries before they happen. Quality data on both reported injuries and injury hazards are important sources of information for prevention planning. Obtaining this information requires that healthcare personnel understand what to report and how to report in addition to being motivated to follow the reporting procedures. Both activities require forms to record relevant data as well as a central repository for the collected information. This section:

• Discusses how to establish an effective process for reporting process and
• Identifies the information that is essential in order to identify risks and plan prevention strategies.

Develop an Injury Reporting Protocoland Documentation Method

Characteristics of a Reporting Protocol. Every healthcare organization should have a written protocol that describes where and how healthcare personnel should seek medical evaluation and treatment after an occupational exposure to blood or body fluids, including percutaneous injury. To ensure timely medical treatment, the protocol should encourage prompt reporting and describe procedures for the rapid provision of medical care during all work hours (day, evening, and night shifts). In some cases, this will require designating different places for exposure evaluation and care. The reporting system should ensure that records of exposed employees and non-employees (e.g., students, per diem staff, volunteers) are maintained in a confidential manner. Exposure reports should be maintained in a designated area (e.g., occupational health, infection control) for purposes of follow-up and record keeping.

Characteristics of a Report Form. In the past, healthcare organizations typically used one report form to document any type of incident involving a patient or employee (e.g., fall, medication error, sharp injury). Although this type of form may provide descriptive information, it generally does not collect sufficient details to analyze injuries or measure prevention improvement.

Several organizations, including CDC, have developed forms to collect detailed information on sharps injuries reported by healthcare personnel. These forms can serve multiple purposes:

• Collecting descriptive information to help monitor sharps injuries and the impact of prevention interventions,
• Providing information to guide the medical exposure management, and
• Providing documentation for meeting regulatory requirements.

To effectively monitor injuries for sharps injury prevention planning purposes, minimal data needs include:

• Name and/or identification number of healthcare worker;
• Date, time, and work location of the injury;
• Occupation of the worker;
• Type of device involved in the injury, and presence or absence of an engineered sharps injury prevention feature on the device involved;
• Purpose or procedure for which the sharp device was being used; and
• When and how the injury occurred.

Regulatory requirement also dictate what information must be collected. Federal OSHA and some state laws or regulations now require a record of the brand and manufacturer of any device involved in an injury to a worker. Devices with engineered sharps injury prevention features  are designed specifically to prevent injuries to healthcare personnel.  Incident reports that involve these devices must include adequate information on these devices to be able to ascertain whether the injury was due to:

• Design flaw,
• Manufacturing defect,
• Device failure,
• Operator error (e.g., failure to activate the safety feature), or
• Other circumstances (e.g., movement of the patient that precluded use of the safety feature).

As with any medical product, if the device or equipment is potentially defective, the lot number and information about the defect should be reported to the Food and Drug Administration. (Healthcare organizations should also review new OSHA procedures for maintaining a sharps injury log, included in the recently revised Bloodborne Pathogens Standard [CFR 1910.1030 (h)] that took effect on April 18, 2001, and for using OSHA Forms 300 Log of Work-Related Injuries and Illnesses and 301 Injury and Illness Incident Report that were required for use by January 1, 2002. Both the log and the individual report forms record many kinds of occupational injuries.)

A sample form for recording information on blood and body-fluid exposures  is included in the toolkit. This form is similar to those used by hospitals participating in NaSH and EPINet. It demonstrates the level of data that some facilities are collecting and using to monitor blood exposures and the effect of prevention interventions. Healthcare organizations may download and print this form for use in their sharps injury prevention program. (Other organizations may have or be developing similar forms.)  In the near future, the CDC's National Healthcare Safety Network (NHSN) will be available to healthcare facilities that wish to enter exposure data into a web-based reporting system.

Toolkit Resource for This Activity:

Blood and Body Fluid Exposure Report Form (see Appendix A-7)

Develop a Process for Hazard Reporting

Many organizations take a proactive approach to injury prevention. They seek and identify hazards in the work environment and encourage all personnel to report observed hazards (e.g., improperly discarded sharps), including the occurrence of near misses. Individuals who report near misses often self-define the miss, but these may include a hand that slipped while working  with a sharp device. Information on these hazards can help identify areas needing attention or intervention. A defined process for reporting hazards empowers personnel to take action when there is a risk for a sharps injury. Organizations that are considering implementing a hazard reporting protocol may find the forms provided in the Toolkit useful.

Toolkit Resource for This Activity:

Environmental Rounds Hazard Observation Form and Sharps Injury Hazard Observation Form (see Appendix A-8)

Develop a Process for Examining Factors That Led to Injury or "Near Misses"

While data on needlesticks are important for examining outcomes, it is also very important to examine the processes and systems that have led to these outcomes. There are several quality improvement tools that can assist in analyzing the processes and systems that contribute to sharps injuries or "near misses." These include:

Process maps or flow chartsare used to describe, step-by-step, the process which is being examined, e.g., sharps disposal, phlebotomy.

Fishbone or cause-and-effect diagrams can be used to identify, explore, and graphically display all of the possible contributors to a problem.  The "bones" of these diagrams are usually divided into at least four areas of "cause": 1) people; 2) equipment; 3) environment; and 4) communication.

Affinity diagramsare used so a team may creatively generate multiple issues or ideas and then summarize the natural groupings in order to understand the underpinnings of a problem and identify possible solutions.

The following Websites from non-healthcare settings are useful for individuals who want to learn more about these tools and consider applying them to sharps injury prevention.

Root Cause Analysis (RCA)is a process for identifying the basic or causal factors that underlie variations in expected performance.  This process is being used widely in healthcare settings to identify factors that lead to adverse patient outcomes or are associated with a "sentinel event" (e.g., medication errors, laboratory errors, falls). The RCA concept also can be applied to sharps injury prevention. For this reason, it is discussed in greater detail than the quality improvement tools mentioned above.

The key to the RCA process is asking the question "why?" as many times as it takes to get down to the "root" cause(s) of an event.

• What happened?
• How did it happen?
• Why did it happen?
• What can be done to prevent it from happening in the future?

The Veterans Administration National Center for Patient Safety has provided a list of triage and triggering questions for root cause analysis for each event under investigation (http://www.va.gov/ncps/toos/html). These questions focus on the relationship between the event and the following possible factors:

• Patient assessment
• Staff training or competency
• Equipment
• Work environment
• Lack of information (or misinterpretation of information)
• Communication
• Appropriate rules/policies/procedures-or lack thereof
• Failure of a barrier designed to protect the patient, staff, equipment or environment
• Personnel or personal issues

For each "YES" response, additional questions about why each of these factors occurred leads to a determination of whether it is a "root cause" of the event, and whether there is a need for further action.  From this, a team may develop a specific action plan and outcome measures in response to the event investigated. A sample form and completed examples are provided to illustrate the RCA process.  This may be a particularly useful approach for those healthcare facilities with very few occupational sharps injuries, in which case a single needlestick might be considered a sentinel event that triggers an investigation.

An RCA event can be investigated by one individual, but it will need to involve the principles associated with the event and a team of individuals who will interpret the findings and assist in developing an action plan. The keys to the success of RCA are:

• Sensitivity to the affected individuals,
• Openness to uncovering the root causes,
• Not assigning culpability, and
• Support for changes that will lead to improved worker safety.

A sample form for performing RCA is provided in the toolkit. An example of a completed form also is provided.

Toolkit Resource for This Activity:

Sample Form for Performing a Simple Root Cause Analysis of a Sharps Injury or "Near Miss" Event (see Appendix A-9)

Resources for additional information on RCA include:

• http://www.va.gov/ncps/tools.html
• http://www.rootcauseanalyst.com
• http://www.sentinelevent.com