1. Creating a Positive Culture of Safety around Sharps Injury Prevention
[NOTE TO PRESENTER: These slides should be tailored to your organization’s activities. This slide set is intended for existing prevention programs.]
Today we’re going to focus on creating and maintaining a culture of safety for preventing needlestick injuries. This presentation is intended to introduce the concept of a culture of safety and how sharps injury prevention fits into a positive and strong culture of safety.
These slides will:
- define a culture of safety and safety climate
- describe the components of a culture of safety
- identify the roles of those involved
- suggest activities specific to sharps injury prevention
- illustrate these concepts in a case example
The following articles may be helpful in further understanding safety culture and climate:
Hospital safety climate and its relationship with safe work practices and workplace exposure incidents Robyn R.M. Gershon, Christine D. Karkashian, James W. Grosch, Lawrence R. Murphy, Antonio Escamilla-Cejudo, Patricia A. Flanagan, Edward Bernacki, Christine Kasting, Linda Martin AJIC: American Journal of Infection Control June 2000 (Vol. 28, Issue 3, Pages )
Anderson E, McGovern PM, Kochevar L, Vesley D, Gershon R. Testing the reliability and validity of a measure of safety climate. J Healthc Qual Mar-Apr;22(2):19-24.
Clarke SP. Organizational climate and culture factors. Annu Rev Nurs Res. 2006;24: Review.
Hui Zhang, Douglas A. Wiegmann, Terry L. von Thaden, Gunjan Sharma, Alyssa A. Mitchell.
SAFETY CULTURE: A CONCEPT IN CHAOS?
Proceeding of the 46th Annual Meeting of the Human Factors and Ergonomics Society. Santa Monica, Human Factors and Ergonomics Society, 2002.
Griffin, M. A. and Neal, A. (2000) Perceptions of safety at work: A framework for linking safety climate to safety performance, knowledge, and motivation. Journal of Occupational Health Psychology 5, 1

2. Culture of Safety: The product of individual and group:
Values
Attitudes
Perceptions
Competencies and
Patterns of behavior
that determine commitment to and the style
and proficiency of an organization’s health and
safety management.
(Reference: Sorra et al, AHRQ Pub No )
Culture of safety has been defined as the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to and the style and proficiency of an organization’ s health and safety management.
Reference: Sorra JS, Nieva VF: Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No ). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality; 2004. 2

3. Safety Culture:
The shared values within an organization with regard to safety.
Expressed in the willingness to evaluate and learn from adverse events
(References: Griffin & Neal, Journal of Occupational Health Psychology, 2000
Zhang, et al. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society, 2002)
It is important to note the difference between safety culture and safety climate, as they are often used interchangeably. Safety culture is the shared values of the organization with regard to safety issues. Safety culture can be evaluated by looking at the organization’s practice of reviewing and evaluating injuries and near misses, and the follow-up measures taken to learn from and prevent similar incidents in the future. 3

4. Safety Climate:
The shared perception, at a point in time, of the safety culture within an organization.
The degree to which employees feel that safety is an organizational value.
(References: Griffin & Neal, Journal of Occupational Health Psychology, 2000
Zhang, et al. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society, 2002)
It is important to note the difference between safety culture and safety climate, as they are often used interchangeably. Safety climate is the shared perception of workers regarding the culture of safety within an organization.
While safety culture is an enduring state, safety climate is the perception of the culture, and may change over time. Safety climate is often measured with worker surveys. 4

5. Components of a Positive Culture of Safety:
Organizational commitment
Demonstrated at the highest levels in the organization
Management involvement
Commitment of resources
Employee empowerment
Freedom to voice concerns about hazards
There are several components to a positive culture of safety. They will be discussed on this and the next slide. In order for a culture to reflect positive attitudes and implement activities directed at improving safety, there needs to be commitment from all levels of the organization. As will be discussed later, both management and staff have important roles in fostering organizational commitment.
Management involvement is essential to translate the organizational commitment to all levels of the organization. This is demonstrated through such activities as the establishment of safety committees, value analysis committees, allocation of financial resources for purchasing safer sharps devices, and developing a post exposure management program in line with current U.S. Public Health Service guidelines.
Employee empowerment is key to ensuring a positive culture of safety. If employees do not believe that they are able to speak up when a hazard is identified, that their concerns about particular devices are not heard, or that they cannot report injuries without fear of reprisal, then their perception of the culture of safety, also known as the safety climate, will be that the organization has not made safety a priority. Employee involvement in decision making on safety issues also helps to ensure buy-in when changes are implemented. 5

6. Components of a Positive Culture of Safety:
Systems to acknowledge safe practices
Reporting systems
Injuries
Safe behaviors
Near misses
Hazards
Additional components to a positive culture of safety are systems that acknowledge safe practices as well as reporting systems.
It is important that positive reinforcement of safe behaviors is provided. This encourages employees to continue to follow safe practices, and to raise safety issues and identify hazards to management. At the same time, accountability for unsafe practices is needed. When evaluating unsafe practices, the focus should be on the work systems, and the gaps that exist which allow for poor decision making.
Reporting systems for injuries, safe behaviors, and near misses are necessary in a positive safety culture. It is important that employees feel that they are able to report injuries, near misses and hazards without fear of reprisal or blame. The type of environment where supervisors and/or management place blame on employees for injuries stifles injury reporting and communication about hazards. A record of injuries and near misses helps to identify hazards and systems that need to be corrected. A record of safe behaviors helps to show what works in a facility and what is different about a group/department/procedure that is preventing injuries. Reporting of safety activities to staff as well as advertising changes made in direct response to hazards identified by staff is also important. It helps to close the loop and lets staff know that management commitment to safety is real. 6

7. Who’s involved? What’s their role?
Management
Acknowledge positive behaviors
Allocate resources for new safety products and processes
Ensure that all staff are aware of and receive training when changes are made
Address suggestions made by staff to improve safety
Both management plays and integral role in developing and maintaining a culture of safety. As mentioned earlier, it is essential that staff be recognized for safe behaviors.
Following the industrial hygiene hierarchy of controls, engineering controls are the preferred prevention measure. Ensuring that funds are available to purchase safety devices is vital to any prevention program. It is equally important to be sure that appropriate staff are hired to ensure that training is provided as often as necessary for staff in the use of safety devices. 7

8. Who’s involved? What’s their role?
Staff
Acknowledge co-workers’ positive behaviors
Provide feedback to management on safety activities and new devices
Participate in training
Voice concerns about hazards to management
Offer solutions to identified hazards
Here you can see that staff also plays an important role in developing and maintaining a culture of safety. Some of the roles for management and staff are similar, but others rely in exchange of ideas between both groups and open communication.
Peer support helps to sustain and reinforce positive behaviors.
Open dialogue with management, who has the power to implement change, ensures a bottom up approach to prevention efforts and alerts management to the success or failure of various prevention measures.
Participating in training, particularly for new devices, is the best way to then be able to evaluate devices as staff will have been instructed on proper use of a device and its safety mechanism.
Often those closest to the front line have the moast valuable insight into what will be an effective solution. Voicing these solutions in addition to identifying hazards is a key component to improving safety and reducing injuries. 8

9. Safety Culture and Sharps Injuries
Nurses with a positive measure of safety culture more likely to accept newly introduced IV catheter safety device
Studies published by Rivers, et al. in a 2003 issue of Nursing Research have shown that when nurses perceive that safety is an important part of the organizational culture, they are more likely to accept a new IV catheter device with safety features. 9

10. Safety Culture and Sharps Injuries
Measures of safety culture are associated with compliance with safe work practices
Employees with higher measures of safety culture were half as likely to experience blood/body fluid exposure incidents
Studies by Grosch et al. have demonstrated that compliance with universal precautions was directly related to the perception by nurses that management supported safety. This work was published in the American Journal of Industrial Medicine in 1999.
Additional work by Gershon et al has shown that hospital staff who believe that safety is an organizational value experienced fewer blood/body fluid exposure incidents. This work was published in 2000 in the American Journal of Infection Control.
Sharps injury prevention needs to occur system wide, as well as at the individual level. Some of those activities are mentioned in this poster, which is available to hospitals. Additional activities relative to sharps injury prevention will be discussed in the following slides. 10

11. Activities specific to Sharps Injury Prevention
Engineering Controls
List of conventional devices identifying where they are used
Inventory of devices with safety features
Rigid sharps disposal containers
Training on the use of devices with safety features
[NOTE TO PRESENTER: TAILOR THIS AND THE NEXT TWO SLIDES AND TEXT TO FIT THE ACTIVITIES IN YOUR HOSPITAL. IT MAY ALSO BE HELPFUL TO SOLICIT ADDITIONAL ACTIVITIES FROM THE AUDIENCE.]
At this hospital, we have instituted several measures to address sharps injuries.
Management has approved budgets adequate enough to purchase devices with integrated safety features. With the help of staff, devices have been identified for trial. With written responses to surveys, staff has indicated their preference for particular devices, which have then been implemented. In addition, sharps disposal containers, appropriate for a variety of clinical settings have been purchased. The containers, along with a structured container replacement system have led to a decrease in the number of disposal related sharps injuries.
All employees using sharp devices have received training on the use of the device and its engineered sharps injury prevention feature. Device related training is provided by the manufacturer’s representative as well as clinical education staff (or infection control). All staff are encouraged to ask for retraining if they are unfamiliar with using the sharps device. 11

12. Activities specific to sharps injury prevention (continued)
Sharps Injury Prevention Committee
Analysis and use of data in decision making
Process for identifying and reporting hazards
Process for reporting exposure incidents
Well developed post-exposure management protocols
Additional measures taken to reduce sharps injuries include:
The formation of a Sharps Injury Prevention Committee, a multi-disciplinary team of managers and staff who meet regularly to review identified hazards and possible solutions as well as utilize sharps injury data in prioritizing prevention measures.
A process for identifying hazards, such as safety rounds, allows management to see what types of issues and hazards need to be addressed. In addition, a system for reporting hazards, either through an intranet based system or a paper reporting system, provides a mechanism for staff to alert management of hazards faced by employees. Hazards can be reported anonymously or by name. This system is used as a way to acknowledge staff for their contribution to the safety process.
All employees have been made aware of the process for reporting exposure incidents. Regular training on who should be notified when an incident occurs, when to report, and where to go to receive treatment is provided for all employees. In addition, posters containing this information are posted throughout the facility. Comprehensive post-exposure management protocols have been developed and implemented. Employees seen in either Occupational Health or the Emergency Department are seen quickly, their injury treated as an urgent case. 12

13. Activities specific to sharps injury prevention (continued)
Bloodborne pathogen training
Upon hire and annually
Review of hazards, prevention measures and reporting protocols
Educational campaigns
In-services
Posters
Training on bloodborne pathogens shall be provided to all employees at risk for exposure. Training follows the OSHA standard, and is provided upon hire and annually thereafter. Educating staff through in-services, bulletins, posters and other reminders about the need to report injuries immediately, as well as the reporting protocols. Employees are to contact Occupational health during the day (8 am -5 pm). All other times, employees are to report to the ED, where they will be fast tracked and treated immediately according to current USPHS guidelines, as required by OSHA.
Regular in-service training is provided for all staff. Training covers situations where staff may be at risk for exposure, devices which are used and the integrated safety features designed to prevent injuries, and work practice control appropriate for various clinical settings (e.g. OR, ED, medical units). Training on injury reporting protocols is also provided.
Posters focusing on sharps injury prevention, along with regular in-services are used as a means to remind staff of safety devices, demonstrate proper disposal methods, and encourage reporting of exposure incidents. These posters are used to compliment regular in-service training. 13

14. Sharps Injury in the OR
[NOTE TO PRESENTER: TAILOR THIS SLIDE WITH SIMILARLY DETAILED INFORMATION FROM AN INCIDENT IN YOUR FACILITY. FOR THE SITUATION BEING DISCUSSED, IT IS IMPORTANT TO THINK ABOUT COMPONENTS OF SAFETY CULTURE AND HOW THOSE COMPONENTS CAN BE IMPROVED.]
This slide describes a recent case of a sharps injury.
A nurse working a 14 hour shift was injured towards the end of her shift when a straight, sharp suture needle punctured her hand. The surgeon was closing fascia during a partial colectomy. In order to minimize the number of tie-offs in closing the surgical site, a longer length of suture material was used. The procedure was scheduled to last for another three hours, and the patient was known to have risk factors for HIV and HCV, although current status was unknown. The nurse was not able to leave the operating room, and thus did not report the injury right away.
Are you able to identify factors that demonstrate a the culture of safety?
If this employee, or other operating room staff were interviewed, what do you think their view of the safety culture would be?
What changes should be made to prevent similar injuries in the future?
[NOTE TO PRESENTER: STOP PRESENTATION TO CONDUCT DISCUSSION.] 14

15. Safety Culture Factors
Long shifts
Use of sharp suture needle
Use of long length of suture material
Unable to leave operating room
Waiting until the end of the shift to report the exposure
Some factors which affect safety culture include:
- length of work shifts
- use of sharp suture needles when blunt needles are appropriate
- length of suture material
- having to wait until the end of the procedure or shift to report the injury
Based on this list, and others you have identified, is this a positive safety culture?
What changes can be made to improve the safety culture?
[NOTE TO PRESENTER: STOP PRESENTATION TO ALLOW FOR DISCUSSION] 15

16. Changes Shorter shifts to avoid fatigue Use of blunt suture needles
Shorter suture material
Identify someone in OR to call Occupational Health for exposures
Triage exposure over the phone
If necessary, Employee Health brings PEP to OR
Here are some changes that other people have come up with.
What do you think the impact of these changes, and those you have mentioned today, will be?
[NOTE TO PRESENTER: STOP PRESENTATION TO ALLOW FOR DISCUSSION] 16

17. Impact of positive changes:
Reduction of hazards with suture needles
reduction / elimination of injuries involving suture needles
Improved reporting
More timely post-exposure management
Improved employee safety and patient care
There have been several measurable effects as a result of the changes that have been implemented.
With the use of blunt suture needles, there has been a reduction in the number of injuries due to suturing.
At the same time, the number of reported injuries in the OR setting has increased slightly, due to better reporting. This is not uncommon in the short term following implementation of a safety program or an improved reporting process. Since a staff member in each OR has been identified to notify Occupational Health at the time of the injury, the reporting process has been made more simple. The exposure incident can be assessed over the phone, and a determination about the need for postexposure prophylaxis can be made quickly. If necessary, postexposure prophylaxis can be delivered to the OR to ensure that it is administered in the time frame desired to achieve the most effective prevention of seroconversion. 17

18. Together we can make it work!
Culture of safety….
…the shared commitment of management and employees to ensure the safety of all care providers and patients in the facility.
Together we can make it work!
A culture of safety involves the shared commitment of management and staff to ensure the safety all care providers and patients in the facility. 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.
You are encouraged to make changes at your unit/department level. Your participation in the previously discussed components of a culture of safety as well as the activities relating to sharps injury prevention is essential to developing and maintaining a strong, positive culture of safety.
Together, we can make it work! 18