Six Sigma targets persistent needlesticks

Environment of care may be key to injuries

There's more to needle safety than a safety device. That conclusion, simple as it may sound, led BJC Healthcare in St. Louis to analyze the environment of care and clinical technique as it seeks to reduce injuries from subcutaneous injections.

Using the Lean Six Sigma quality improvement process enables the 13-hospital BJC Healthcare to uncover complexities that aren't apparent just from a review of basic injury data, says Christine Zirges, RN, ACNS-BC, CIC, infection prevention consultant for occupational health services, who is scheduled to speak at the upcoming 2009 conference of the Association of Occupational Health Professionals in Healthcare (AOHP). The conference, to be held in Portland, OR, in September, will encompass a range of issues, from respiratory protection to occupational health best practices.

"It's easy to jump to conclusions or veer off course [when analyzing injury data]," says Zirges. "Using the tools in the [Lean Six Sigma] toolkit and staying on course really does guide you in the right direction."

While other safety devices were very successful in reducing injuries, injury rates for one particular device used in intramuscular and subcutaneous injections at one hospital rose after implementing a safety-engineered needle from 0.21 per 100,000 productive hours to 0.38 per 100,000. Additional training in the use of the device had not resolved the problem.

In search of answers, BJC used the DMAIC framework: D efine the problem and goals. M easure and collect data, while looking for cause and effect. A nalyze data to look for cause and effect. I mprove the process. C ontrol or correct any deviations and continue to monitor the process.

Drilling down into the needlestick data, Zirges and her Lean Six Sigma team (which included staff nurses) discovered that the needlesticks were occurring specifically with subcutaneous insulin injection immediately after the needle was removed from the patient and before the safety device was activated. Even a BJC hospital that used a different device for the same procedure was having a similar problem.

To gather more information on the cause, Zirges conducted observations. She sometimes had to wait hours to observe the specific at-risk injection, but in the process she learned a lot about the environment in which the nurse practices.

"The environment in which the nurse works is very loud. You often want to have an audible click [from the safety device]," she says. "We didn't know if you could hear the click in a busy environment."

Nurses sometimes reported that a sudden movement of the patient precipitated the stick. But Zirges also noted awkward postures. "Nurses were giving injections in a very contorted position. Some were standing behind the patient, some were leaning forward," she says.

An analysis also showed that many of the injuries were to the left thumb. To perform the stick, the nurses were pinching the skin with their left hands.

With support from the vendor, the BJC department of nursing professional practice and IV Therapy created a competency checklist for the insulin injection procedure. It was added to competency training for all the hospitals.

Yet the needlesticks for subcutaneous insulin injection remained variable - up one month, down another. This was a challenge for the Lean Six Sigma team.

With the assistance of Occupational Health at BJC, a new data collection effort will collect detailed information from all 13 hospitals, which include small rural hospitals, community hospitals, a large tertiary care center, and a pediatric hospital.

When these specific subcutaneous needlesticks occur, nurses will report the position of the patient (in a chair or bed?), the position of the nurse (was she leaning over?), the bed position and other bedside equipment (was the area crowded?) and whether there was any unexpected patient movement. They also want to know whether the nurse was right- or left-handed.

"We discovered we weren't asking the right questions to drill down into this environment of care [issue]," Zirges says. "The more we looked, the more questions we had."

The Lean Six Sigma process can be time-consuming, but it will pay off by helping the hospital get to the root cause of problems, she says. It can be just as effective in evaluating other injuries, such as patient handling.

"In my opinion, the environment in which the nurse works is very important," Zirges points out. "Don't just look at the numbers. Be careful not to make assumptions.

"We're using a good process. We have that [safety] culture that supports us," she says. "[Lean Six Sigma] really does work."

(Editor's note: The 2009 AOHP conference will be held in Portland, OR, Sept. 16-19. A conference brochure is available at