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Imagine you're an SPD technician, unloading your hundredth case cart
of the shift in Decontam. As you remove instruments from a Major 1 Tray, your attention momentarily shifts to turn off the faucet. Suddenly, you feel a sharp pinch on your index finger. Looking down, you see a number 5 suture needle still held in place by
a needle holder, now with a mixture of the patient’s blood, and your own. This scenario, unfortunately, is not uncommon and highlights a critical issue in healthcare safety: sharps left in surgical trays.
The safety of Sterile Processing Department (SPD) technicians is often
overlooked when discussing sharps safety. While operating room (OR) staff receive extensive training on handling sharps, SPD techs are not typically trained for sharps removal. This discrepancy in training can lead to serious consequences.
The Association of periOperative Registered Nurses (AORN) and the
Association of Surgical Technologists (AST) have established rigorous standards for sharps handling in the OR. These standards include proper techniques for passing sharps, using neutral zones, and performing accurate counts. However, SPD techs, who are responsible
for cleaning and sterilizing instruments, are not required to undergo this specialized training. When an SPD tech encounters a sharp left in a tray, they're faced with a task they're not trained to perform safely. This puts them at risk of injury and potential
exposure to bloodborne pathogens. The impact of such an incident goes beyond physical harm, potentially causing significant liability for both the technician and the healthcare facility.
In the event of a sharps injury, a complex process of source testing
is initiated. This involves contacting the patient from whom the instruments came and conducting tests for bloodborne pathogens. This process not only adds stress to the injured technician but also creates additional costs for the hospital. Moreover, the technician
may face anxiety and uncertainty while awaiting test results, potentially impacting their mental health and job performance.
Bloodborne
pathogen transmission rates in healthcare settings vary by pathogen, with HIV having a relatively low transmission rate of 0.3% after percutaneous exposure, compared to higher rates for Hepatitis B (6-30%) and Hepatitis C (1.8%).
The overall risk of transmission depends on multiple factors, including the type and size of exposure, viral load in the source patient's blood, and the specific healthcare setting, with certain specialties like surgery and emergency medicine facing higher
risks of occupational exposure.
Sharps left in trays don't just pose a risk to SPD professionals;
they also indicate a potential patient safety issue. OR teams are required to perform a final count of all sharps and potential retained items at the end of each procedure. When a sharp is found in a tray post-operation, it raises serious questions about the
accuracy of these counts. If the count was reported as correct, it means a potentially dangerous item was unaccounted for during the procedure. Conversely, if the count was reported as incorrect, it necessitates immediate corrective actions to ensure no objects
were retained in the patient. Either scenario points to a breakdown in crucial safety protocols, potentially putting patients at risk.
The presence of sharps in instrument trays is often symptomatic of
larger issues within the OR, particularly regarding compliance and accountability. Best practices for OR safety include rigorous reporting systems, comprehensive staff training, and clear accountability measures.
When a sharp is found in a tray, it's crucial that OR staff are held
accountable. This may involve requiring them to come to the decontamination area to remove the sharp safely. Consistent reporting of such incidents allows hospitals to set benchmarks, track trends, and implement targeted process improvement measures. In some
cases, if the number of reported sharps incidents exceeds a specified threshold, it may trigger a surgical standdown. This measure underscores the seriousness of the issue and provides an opportunity for comprehensive review and retraining.
Creating a culture of safety in the OR requires ongoing education
and reinforcement of proper protocols. This includes regular training on sharps handling, emphasis on the importance of accurate counts, and fostering an environment where staff feel comfortable reporting errors without fear of punitive action.
Healthcare facilities must prioritize enhanced training, extending
sharps safety education to SPD technicians to equip them with the necessary knowledge and skills for safely handling unexpected sharps. This training should be complemented by improved communication between OR and SPD staff, fostering a shared understanding
of the importance of proper sharps handling and its impact on overall safety. Implementing robust, user-friendly reporting systems encourage staff to report all sharps-related incidents without fear of reprisal. These systems should be supported by regular
audits of sharps handling practices in both the OR and SPD to identify areas for improvement.
To further enhance safety measures, healthcare facilities should consider
integrating technology solutions, such as unique device identifier tracking for surgical instruments, to improve accuracy in instrument counts and tracking. Recognizing the potential psychological impact of sharps injuries, facilities should provide readily
available support for affected staff members. This acknowledgment of the mental and emotional toll of such incidents is an essential component of a comprehensive safety approach. Many of us have been there when a safety incident took place in the middle of
the night without a department manager to reach out to, employee health to contact, or experienced coworkers who were familiar with the protocol for Bloodborne Pathogen Exposure.
The issue of sharps left in surgical trays is more than just an inconvenience;
it's a serious safety concern that affects multiple aspects of healthcare delivery. From the potential harm to SPD technicians to the risks posed to patients and the broader implications for OR safety culture, this problem demands immediate and sustained attention.
By implementing comprehensive training programs, fostering a culture of accountability, and leveraging technology and data-driven insights, healthcare facilities can significantly reduce this risk.
Ultimately, addressing this deep tissue issue requires a commitment
from all levels of healthcare organizations. From frontline staff to hospital administrators, everyone has a role to play in ensuring that every surgical tray is free from unexpected sharps, safeguarding the well-being of both patients and healthcare professionals
alike.
Garrett Hollembeak
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