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

Contents:

OPERATIONAL PROCESSES

The following section describes five operational processes that are viewed as essential elements of any sharps injury prevention program. Toolkit resources to assess, implement, or evaluate these processes are included in the appendices.

Institutionalize a Culture of Safety in the Work Environment

Introduction

Many strategies to reduce sharps injuries focus on individual- or job/task-level improvements (e.g., implementing appropriate safety devices, using safe work practices).  However, this particular strategy considers sharps injury prevention in the context of a broader organizational perspective of safety, namely institutionalizing a culture of safety to protect patients, personnel, and others in the healthcare environment. The following describes safety culture concepts and discusses why having a safety culture is important to the success of a sharps injury prevention program.

Safety Culture Concepts. From an organizational perspective, culture refers to those aspects of an organization that influence overall attitudes and behavior. Examples include:

• Leadership and management style
• Institution mission and goals
• Organization of work processes

An organizational culture is the accepted norms that each place of work establishes for day-to-day tasks. It is shown to be strongly associated with workers' perceptions of job characteristics and organizational functioning (107).

A culture of safety is the shared commitment of management and employees to ensure the safety of the work environment. A culture of safety permeates all aspects of the work environment. It encourages every individual in an organization to project a level of awareness and accountability for safety. Employees perceive the presence of a culture of safety based on multiple factors, including:

• Actions taken by management to improve safety,
• Worker participation in safety planning,
• Availability of written safety guidelines and policies,
• Availability of appropriate safety devices and protective equipment,
• Influence of group norms regarding acceptable safety practices, and
• Socialization processes around safety that personnel experience when they first join an organization.

All of these factors serve to communicate the organization's commitment to safety.

Value of Institutionalizing a Culture of Safety to Healthcare Organizations. Most of our knowledge about safety culture comes from the manufacturing sector and heavy-industry work settings, where it was first studied. Critical determinants of the successful safety programs in early research include:

• Management's involvement in safety programs,
• High status and rank for safety officers,
• Strong safety training and safety communications programs,
• Orderly plant operations, and
• An emphasis on recognizing individual safe performance rather than a relying on punitive measures.

The concept of institutionalizing a culture of safety is relatively new for the healthcare industry and much of the focus is on patient safety. However, recent studies in some healthcare organizations link measures of safety culture to:

• Employee compliance with safe work practices, and
• Reduced exposure to blood and other body fluids, including reductions in sharps-related injuries (94, 96).

Safety culture is also relevant to patient care and safety. According to an Institute of Medicine (IOM) report, To Err is Human (109), medical errors represent one of the nation's leading causes of death and injury. The report estimates that 44,000 to 98,000 deaths occur in U.S. hospitals each year. Although the report acknowledges that causes of medical error are multifaceted, the authors repeatedly emphasize the pivotal role of safety culture. Thus, whereas the focus of this workbook is on healthcare personnel safety, strategies related to safety culture also have important implications for the health and welfare of patients.

Strategies for Creating a Culture of Safety

To create a culture of safety, organizations must address those factors known to influence employees' attitudes and behavior. Organizations must also direct measures to reduce hazards in the environment. Although many factors influence a culture of safety, this workbook emphasizes those that are believed to be the major determinants of a safety culture.

Ensure Organizational Commitment. Organizations can use three important strategies to communicate their involvement in and commitment to safety:

• Include safety-related statements (e.g., zero tolerance for unsafe conditions and practices in the healthcare environment) in statements of the organization's mission, vision, values, goals, and objectives;
• Give high priority and visibility to safety committees, teams, and work groups (e.g., occupational health, infection control, quality assurance, pharmacy, and therapeutics), and ensure direct management involvement in the evaluation of committee processes and impact
• Require action plans for safety in ongoing planning processes. (e.g., an action plan for improving the culture of safety for sharps injury prevention could be one element in an overall safety culture initiative.)

Management can also communicate a commitment to safety indirectly by modeling safe attitudes and practices. Healthcare professionals in positions of leadership send important messages to subordinates when they:

• Handle sharp devices with care during procedures,
• Take steps to protect co-workers from injury, and
• Properly dispose of sharps after use.

Similarly, managers should address sharps hazards in a non-punitive manner as soon as they are observed and discuss safety concerns with their staff on a regular basis. This will positively reflect the organization's commitment to safety and build safety awareness among staff.

Involve Personnel in the Planning and Implementation of Activities That Promote a Safe Healthcare Environment. Involving personnel from various areas and disciplines while planning and implementing activities improves the culture of safety and is essential to the success of such an initiative. Those personnel who participate on committees or teams created to institutionalize safety serve as conduits of information from and to their various work sites. They also legitimize the importance of the initiative in the eyes of their peers.

Encourage Reportingand Removal of Sharps Injury Hazards. Another strategy for institutionalizing a culture of safety is to create a blame-free environment for reporting sharps injuries and injury hazards. Healthcare personnel who know that management will discuss problems in an open and blame-free manner are more likely to report hazards. Healthcare organizations can also actively look for sharps injury hazards by performing observational rounds and encouraging staff to report near misses and observed hazards in the work place. (See Implement Procedures for Reporting Sharps Injuries and Injury Hazards.) Once identified, hazards should be investigated as soon as possible to determine the contributing factors, and actions should be taken to remove or prevent the hazard from occurring in the future.

Develop Feedback Systemsto Increase Safety Awareness. A number of communication strategies can provide timely information and feedback on the status of sharps injury prevention in the organization. One strategy incorporates findings from hazard investigations, ongoing problems with sharps injuries, and prevention improvements into articles in the organization's newsletter, staff memoranda, and/or electronic communication tools. It is important to communicate the value of safety by providing feedback when the problem is first observed and commending improvements. Another strategy is to create brochures and posters that enhance safety awareness. Such materials can reinforce prevention messages and highlight management's commitment to safety.

Promote Individual Accountability. Promoting individual accountability for safety communicates a strong message about the organization's commitment to a safe healthcare environment. In order for accountability to be an effective tool, all levels in the organization must comply. An organization can promote individual accountability for safe practices in general-and sharps injury prevention in particular-in many ways. One way is to incorporate an assessment of safety compliance practices in annual performance evaluations; for managers and supervisors, this might include evaluating methods used to communicate safety concerns to their subordinates. Organizations might also consider having staff sign a pledge to promote a safe healthcare environment. This could be incorporated into hiring procedures and/or as part of an organization-wide safety campaign.

Measuring Improvements in the Safety Culture

Data from four possible sources can measure how improvements in safety culture affect sharps injury prevention:

• Staff surveys on perceptions of a safety culture in the organization and reporting of blood and body- fluid exposures (Appendices A-2 and A-3),
• Sharps injury reports (Appendix A-7),
• Hazard reports (Appendix A-9-1), and
• Observational hazard assessment reports (Appendix A-9-2).

Each of the above tools can demonstrate changes over time that serve to indicate improvements in the safety culture.  For example, decreased frequency of selected items on a blood exposure report form can  reflect an increased safety consciousness (e.g., improperly discarded sharps, collisions between personnel that result in a sharps injury). Also, periodic (e.g., every few years) personnel surveys on perceptions of safety and exposure reporting are likely to reflect positive changes in the organization's commitment to safety. Hazards will also decrease as problems are addressed and corrected. If no improvements are detected, the sharps injury prevention leadership team should reassess its strategies and revise the performance improvement action plan.

Additional information on implementing a culture of safety is available at the following Websites:

• http://www.patientsafety.gov/