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Root-Cause Analysis

Vol. 9 •Issue 9 • Page 29
Root-Cause Analysis

Recent research points to working conditions contributing to needlestick injury

One bloodborne pathogen infection case from a needlestick injury could add up to $1 million for testing, follow-up, lost time and disability costs.1 Multiply that number by the 1,000 healthcare workers estimated to contract serious infection annually from needlestick and sharps injury, and the case is strongly made for adopting safer devices.1

While needlestick prevention is important, one nurse has dug a little deeper. Conducting a root-cause analysis, Alison M. Trinkoff, ScD, RN, FAAN, professor at the University of Maryland School of Nursing, Baltimore, attributes nurses' working conditions along with exposure to needlesticks with increasing the risk of needlestick injury.

In her study, Trinkoff concludes, "Despite advances in protecting workers from needlestick injuries, extended work schedules and their concomitant physical demands are still contributing to the occurrence of injuries and illness to nurses."2

Who is most at risk? According to Trinkoff's research, nurses in areas with the greatest use of needles combined with long hours and high acuity — emergency, trauma, critical care, OR — sustain the most injuries.

Fatigue Factor

Needlestick injury is a "complicated mix" of scheduling issues, rushed environment, number of needles used in the shift and whether the device is actually safe, Trinkoff said.

In terms of the scheduling issue, "Nurses need to be rested, practice when they are not worn out, and have just a little bit of vigilance," she said. "Part of the problem is the time at work and part of it is scheduling and not getting time off to rest between long shifts."

According to Trinkoff's study, hours worked per week; shifts with fewer than 10 hours off between; number of days worked in a row and work on days scheduled off strongly correlated with sustaining a needlestick injury. "In general, everyone has limitations when they can practice their best," Trinkoff told ADVANCE.

One forward-thinking suggestion, Trinkoff said, is for hospitals to start building time in a nurses' shift to nap in a designated room. "This is one area that has a lot of potential — it would be new thinking for hospitals." This idea already is in place in some Canadian hospitals, she said.

Selecting Safe Devices

Even with rest, many needlestick injuries can be prevented in part by the safety design of the device used. Some safer needles are actually much more protective than others and some tasks require needles that still have not yet been designed with safety features.

In the American Nurses Association's "Needlestick Prevention Guide," the authors described what to look for when selecting safety devices. The recommendations include:

  • Go needleless — Select a device that is needleless, has a safety feature built in and works passively, meaning it does not require activation by the user.

  • Evaluate safety features — For devices with user activation, the safety feature should be engaged easily with a single-handed technique, allowing the clinician's hands to stay behind the sharp edge.

  • Seek activation signs — Devices ought to make a clicking sound or have another identifiable feature, such as changing color, to tell the user the device is activated.

  • Check for deactivation — The safety feature cannot be deactivated and remains protective through disposal.

  • Think about needle sizes — If the device uses needles, it performs reliably with all needle sizes.

  • Examine effectiveness — The device should be practical, easy to use and effective in patient care, such as minimizes discomfort or bruising.3

"I suggest nurses evaluate new devices carefully and determine whether they are using the best ones available in terms of protecting workers who get stuck," Trinkoff said. "Evaluate what you have and whether they are the best choices É There is a variation in the quality of the protective devices. If you're spending the money for the protection for workers, make sure they are getting the best possible ones."

Who Is Getting Stuck?

Trinkoff's research also correlates high average daily needle use with increased risk of getting stuck. Nurses who worked with needles 21-40 times or more a day were 2-3 times more likely to sustain a stick injury.

This explains why staff and hospital nurses in emergency, adult critical care, OR, oncology, transplantation, AIDS, cath lab, diagnostics or hemodialysis, presented with the highest percentage of needlestick injury in the study.

"To some extent, these are the more needle-using positions with nurses working longer hours," Trinkoff said. "Having safer needles available or a needleless system available brings less opportunity to be stuck. All those precautions and devices can serve a real purpose."

Needleless Systems

At The Community Hospital, Munster, IN, John Olmstead, MBA, RN, surgical services director, was not surprised to hear these findings. He concurs greater usage of needles in a high acuity environment and working long hours presents a grave risk for RNs, especially in the emergency department.

"The ED is a rushed environment. With IV injections and drawing up medications with needles, nurses are using more needles. Plus, ED is more shift work," he said.

Elsewhere in The Community Hospital, unit nurses use a needleless system, which has greatly reduced their needlestick injury rate in the 6 years it has been in place. Infection control now is looking at the ED and OR to bolster safety with new devices.

Another common factor Olmstead has observed is the impact of fatigue on errors — on surgeons who inadvertently "stab" the OR nurse during a procedure.

"We are a larger hospital and pay more attention to fatigue, more so with the surgeons," he said. "Nurses are the victims because surgeons are doing the suturing."

Making Long-Term Changes

Both Olmstead and Trinkoff believe in the importance of creating a nonpunitive environment. And in the unfortunate event of an injury, do not just record the injury, uncover the cause and work to rectify it.

"Encourage people to discuss the circumstances and not blame the person being stuck," Trinkoff added. "Ask what was happening and the circumstances that might be repeated. Look for patterns and break the chain of events occurring."

References for this article can be accessed at Click on Education then References.

Erin James is senior associate editor at ADVANCE.


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