1. Quality Improvement Project June 2016:
9/9/2018 2:31 PM
Quality Improvement Project June 2016:
Injuries from Breaking Glass Ampoules Containing Medications
Justin Merkow, MD
Ben Abrams, MD
Melvina Cheung MD
Faculty Advisors: Dr. Tony Oliva, Dr. Maung Hlaing
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2. Injuries from Glass Ampoules
Background
- Understanding the Problem
Methods
- Proposed Interventions
Findings : metrics to measure outcomes
- Outcomes, Process and Balancing Measures
Conclusions & Recommendations
- Recommend Areas of Improvement
- Plan, Do, Study, Act cycle

3. Background – Sharps Injuries from Glass Ampoules
Over one quarter of sharps injuries occur while opening glass ampoules.
The costs of injuries is high and may include suture of laceration, weeks of rehabilitation and loss of salary (Matson, K. (2000) “States begin passing sharps and needle-stick legislation to protect health care workers.” AORN Journal 72(4): , 705-7).
One in four anesthesia staff have been injured in the past (Parker, M. R. (1995). “The use of protective gloves, the incidence of ampoule injury and the prevalence of hand laceration amongst anaesthetic personnel.” Anaesthesia 50(8): 726-9).

4. Background: Understanding the Problem
What : Injury from opening glass ampoules
Why : affects providers often
Who : anesthesiologists, pharmacists, hospital, anesthesia techs
When : Daily risk
Where : OR, outpatient clinic, wards

5. Background: Process Map

6. Background: Root Cause Analysis

7. Methods to Improve
Interventions proposed

8. Methods : Revised Process Map

9. Findings: Metrics to Measure Outcomes
SMART Goals (Specific, Measurable, Aggressive, yet Achievable, Relevant, Time Bound)

10. Recommendations Area of Improvement Overall Goal
1. Increased availability of tools to open vial safely
Reduce no. of injuries
2. Improve knowledge on safety and correct way to open vials
Educational program
3. Create a protocol
Universal compliance to protocol
4. Prioritize safety focus
Understanding that improving safety improves efficiency and lowers cost

11. Conclusion & Recommendations
Plan, Do, Study, Act (PDSA) cycle
Determine whether vial breakers are effective
Costs
Different brands of vial breakers
Change educational methods
Pharmacy or dept. inertia
Identify target settings
Check box on block note
Report on QI form
Reduce number of injuries related to glass vials
1. Plan
2. Do
3. Study
4. Act

12. References
Carreretto, AR. et al. “Glass Ampoules: Risks and Benefits”. Rev Bras Anestesiol. 2011; 61: 4:
Haldar, R. et al. “Opening Snap Off Ampoules – A Safer and Uncomplicated Method”. Letters to the Editor. Brazilian Journal of Anesthesiology (English edition). Nov-Dec (6):
Matson, K. (2000) “States begin passing sharps and needle-stick legislation to protect health care workers.” AORN Journal 72(4): ,
Parker, M. R. (1995). “The use of protective gloves, the incidence of ampoule injury and the prevalence of hand laceration amongst anaesthetic personnel.” Anaesthesia 50(8):
Stroker, R. “Preventing Injuries from Glass Ampoule Shards: Advances in Ampoule Safety”. Managing Infection Control. Oct 2009;