Unsafe injections point to poor 'safety climate'
Unsafe injections point to poor 'safety climate'
CDC to investigate injection safety in three states
At the Endoscopy Clinic of Southern Nevada in Las Vegas, it was not uncommon for a nurse anesthetist to remove the needle from a syringe and reuse the syringe even on another patient, public health investigators report. This practice, uncovered earlier this year, led to a cluster of hepatitis C in six patients (five of whom had their procedures on the same day). The facility was ultimately shut down as 40,000 patients were urged to undergo testing for hepatitis C.
The Nevada case has raised important questions about both patient and employee safety and the absence of a "safety culture" that would reinforce proper practices.
It was not an isolated case. In 2007, unsafe injection practices identified at three outpatient clinics in two states led to the notification of 28,000 patients, according to the Centers for Disease Control and Prevention.1 That included 8,500 patients of a pain management clinic in Long Island.
The CDC and the Centers for Medicare & Medicaid Services (CMS) now are collaborating on special surveys of ambulatory surgery centers in Oklahoma, Maryland, and North Carolina, as they seek to determine whether unsafe injection practices are occurring elsewhere.
"Injection safety has not been looked at closely in the traditional inspection process," says Joe Perz, DrPH, acting prevention team leader in the CDC's Division of Healthcare Quality Promotion (DHQP).
Removing a needle from a syringe is prohibited by the Bloodborne Pathogen Standard of the U.S. Occupational Safety and Health Administration. It places the health care worker at risk of a needlestick from a contaminated needle. Reusing a syringe and then drawing additional medication from a multiuse vial also clearly places patients at risk.
"It's very disconcerting to see this happen in this day and age," says Michael Bell, MD, CDC's associate director for infection control in DHQP.
A CDC investigation at the clinic revealed that one nurse anesthetist reused syringes while another did not. Beyond the obvious concerns about unsafe injection practices, there are broader issues: What workplace attributes influence employees to do the right thing? What climate contributes to inadvertently or even knowingly violating accepted practice?
IC guidelines were clear
The nurse anesthetists at the Nevada clinic should have known that reusing syringes was not standard practice. The American Association of Nurse Anesthetists (AANA) in Park Ridge, IL, first published its infection control guideline in 1998.
"It clearly states, for infection control reasons, that needles and syringes are single use items," says Lisa J. Thiemann, CRNA, MNA, acting senior director of the association's Professional Practice Division. To obtain certification, nurse anesthetists take a test that includes questions on infection control, she says.
Yet some clinicians beyond just nurse anesthetists fail to understand the importance of the single-use provision. "The perception was that it's OK to inject higher up in the intravenous line because it's farther away from the blood flow," Thiemann says.
In 2002, after syringe reuse in Oklahoma and New York led to transmission of hepatitis C, the AANA sponsored a national survey of anesthesiologists, nurse anesthetists, oral surgeons, and other nurses and physicians. In the survey, 3% of anesthesiologists and about 1% of nurse anesthetists acknowledged reusing needles and/or syringes on multiple patients. While those percentages are small, they still represent a significant number of clinicians, says Thiemann.
The reuse may occur out of a lack of understanding about the risk of infection, Thiemann says. In light of the recent outbreak, the AANA has been working with the CDC and the Food and Drug Administration to prevent reuse of syringes and needles and emphasize that they should be "never events."
"We're hoping to engage multiprofessional groups to shine a light on this," she says. "It's not purely an anesthesia-related issue. It occurs across all layers of health care."
What makes the difference between a workplace where health care workers comply with safety and those that don't? It comes down to the "safety climate the shared perceptions that workers have about the importance of safety in their work environment," says Jim Grosch, PhD, MBA, a research psychologist with the National Institute for Occupational Safety and Health in Cincinnati.
"The safety climate seem to predict a lot about what people will do in terms of safety behaviors," he says. "There are some hospitals that you can just walk into and they have a certain feeling. Things are done very carefully, very precisely, and they follow the guidelines."
Competing pressures
Often, there are competing pressures to perform tasks safely but also to work quickly and save money, he says. Grosch studied adherence to universal precautions (now called "standard precautions") and found that management commitment to safety was a major factor.2
"We found the individual level variables [such as occupation, demographics, or even risk-taking tendencies] predicted very, very little in terms of safety behaviors," he says.
It's not enough for management to talk about safety, notes David DeJoy, PhD, professor in the College of Public Health and director of the Workplace Health Group at the University of Georgia in Athens. "It's not just the importance that management ascribes to safety, but it's the importance of safety as compared to other organizational priorities [that matters]," he says.
In a study of hospital safety climate as it relates to needle safety, Robyn Gershon, DrPH, professor in the Mailman School of Public Health at Columbia University, and colleagues found that "senior management support for safety programs, absence of workplace barriers to safe work practices, and cleanliness/orderliness of the worksite were significantly related to compliance."3
Amid the pressures of day-to-day work, what actions do the managers reward? "Workers feel they're overworked, so there are a lot of time demands. They need to get things done quicker and more efficiently," says Janet L. Barnes-Farrell, PhD, division head of industrial and organizational psychology at the University of Connecticut in Storrs.
If managers reward efficiency but don't emphasize or reinforce safety, then workers get the message.
A simple way to convey the importance of safety is to provide regular feedback for example, to periodically post the needlestick rates by department. "Whatever you give people feedback on they tend to attend to more closely. If that includes their safety behavior, then they tend to pay more attention to it," says Barnes-Farrell.
Why didn't someone speak up?
In the Nevada case, why did one nurse anesthetist follow proper procedures but fail to blow the whistle on the improper practices?
In a tightknit group of employees, a worker may feel uncomfortable saying something critical about a colleague or even questioning the status quo, says Barnes-Farrell. That is why it is important for managers to take the lead and set the standard, she says.
Training is necessary to make sure all employees know the proper practices and the expectations of the organization. But in a workplace with a strong safety culture, employees would feel comfortable expressing safety concerns, says Thiemann.
"There needs to be a nonpunitive culture to report practices that pose harm to patients," she says.
References
1. Labus B, Sands L, Rowley P, et al. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic Nevada, 2007. MMWR 2008; 57:513-517.
2. Grosch JW, Gershon RR, Murphy LR, et al. Safety climate dimensions associated with occupational exposure to blood-borne pathogens in nurses. Am J Ind Med 1999; 1(suppl):122-124.
3. Gershon RR, Karkashian CD, Grosch JW, et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control 2000; 28:211-221.
At the Endoscopy Clinic of Southern Nevada in Las Vegas, it was not uncommon for a nurse anesthetist to remove the needle from a syringe and reuse the syringe even on another patient, public health investigators report.Subscribe Now for Access
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