Sharps Injury Prevention Program: Root Cause Analysis of Sharps Injury or near Miss Event at a Multi-Facility Medical Center

Abstract

ISSUE: The Detroit Medical Center implemented a Safer Sharps Committee in 1999 to reduce sharps injuries in healthcare personnel. Primary goals included improvement of work practices and evaluation and implementation of safety sharps devices. Procedures for reporting and documenting employees' exposure to blood and body fluids have been standardized. Root cause analysis is a quality tool utilized after an event in order to prevent future occurrences. A root cause analysis was performed after events or near misses that lead to sharps injuries. PROJECT: The Detroit Medical Center was awarded a CDC Foundation Grant to assess its sharps injury prevention program utilizing the tools provided in the CDC Workbook. A root cause analysis was performed by the institutions utilizing the CDC sample form for performing a root cause analysis. The events analyzed included safety butterfly injury, Huber needle leak and disconnect, safety insulin syringe injury and hand passing sharps in the OR. RESULTS: The multidisciplinary teams were led by a facilitator to assist the group in identifying causation and a leader who was clinically familiar with the event. Staff were able to verbalize their thoughts without judgement in a no fault environment. Each question relatiing to contributing factors in the sample form was reviewed by the team to deterimine if they were related to the event. Risk factors were identified and action plans were developed for risk reduction strategies. LESSONS LEARNED: Root cause analysis is an effective tool to use when evaluating sharps injuries. The CDC Workbook form is a short concise tool for initiating a root cause analysis. Further expansion of the contributing factors in more detail and use of a fishbone diagram may be useful in facilitating a more in depth analysis. Healthcare worker participation in discussion of the events may lead to increased awareness of the importance of safety in their clinical practice and improved compliance with safety devices.