Let others know...

SPD Safety Shouldn’t Be a Near Miss: Why Incident Reporting of Sharps Matters to Everyone

Imagine the sheer weight of fire and brimstone that would rain down upon a sterile processing department that mistakenly left a blade in a #3 knife handle inside a tray that was sterilized and made its way back into the operating room. Not only that, imagine if that blade punctured the hand of your chief neurosurgeon, or almost did.

There might as well have been an atomic bomb dropped in your SPD breakroom compared to the cultural destruction this kind of event would cause. Red-faced surgeons might be deriding your SPD manager and asking for someone to be fired, risk managers might be setting up full scale root-cause analysis workgroups, and you might be put on the spot to explain how you’re going to make sure this never happens again. Whatever the context and scenario, you can be assured this event will have a documentation trail. Someone, somewhere is going to write it down, type it in, and ensure some kind of real follow-up occurs.

What about us?
In one sense, we all agree that a disposable sharp making it back to the operating room and injuring or potentially injuring a perioperative staff member is worthy of serious reactions and thorough documentation. But as I mentioned at the outset, we don’t necessarily have an issue in our industry with making sure these SPD-to-OR errors and near misses are documented. The real, sad, and professionally unacceptable reality is that when the roles are reversed, and the disposable sharp comes down from the OR in a used tray for decontamination, potentially or actually injuring our sterile processing technicians, there is often little more than an “oops!” in response.

There are exceptions to this dynamic, but in far too many facilities across the country today, when the near miss is an OR-to-SPD error, there is almost an unspoken assumption that whatever the reason for the contaminated sharp, it simply couldn’t be helped. Often these decontamination near misses are not even documented and, in fact, many quality and risk departments encourage sterile processing leaders not to use the hospital incident reporting system, implying that these situations are part of the dangers of surgical instrument contamination. Leaders are encouraged to simply notify their OR leaders and hope for the best. In light of these types of internal pressures, countless sharps exposures and near misses in our SPDs are going undocumented, unaddressed, and our people are being left in harm’s way to defend themselves against unnecessary risks in an already difficult job.

What’s good for the doctor is good for our decontaminators
If there were a list of things for which a sterile processing leader should draw a line in the proverbial sand, using the facility’s incident reporting system to document decontamination sharps events should be one of them. There is no more dangerous point in the instrument workflow to be exposed to an unnecessary sharps risk than during the decontamination phase where technicians are working in poor lighting, with water, colored chemical detergents, slippery gloves, disheveled instrument trays, unstable case carts, and deep sinks. There is no question about the contaminated nature of the device at this point, no chance that it happens to be clean, and it is definitely no longer sterile. An exposure here is bad news, no matter what the lab report finally shows.

Fundamentally, there should be no difference in the importance we place on a sharps-based near miss event for a surgeon or a sterile processing technician. If a hospital would document a near miss or injury to a doctor due to a disposable sharp that was not properly disposed of, the same should be true for a decontaminator who finds a surgical blade, suture needle, or other sharp that has been left in the tray after initial use. All members of the perioperative continuum of care, regardless of their title, deserve the same level of protection from and follow-up to the dangers of contaminated sharps.

The power of transparency: from near miss to never event
It would be nearly impossible to get us from the current state of affairs to a truly transparent tracking and trending of sharps events in decontamination without leveraging the existing incident reporting systems in our hospitals. These systems are already in place in nearly every facility in the U.S. By design, they already have multidisciplinary eyes on the incidents themselves, and already have the ability to trend historical data to measure improvement and increasing risk. Even though they are primarily used for patient-related events because the decontamination risks we are talking about exist due to individual patient exposure to these instruments, there is little logic in trying to carve out sterile processing events as something undeserving of documentation in this system.

While particular incident reporting systems are by no means perfect, or even user-friendly at times, they do force transparency into these safety events in a way that traditional department follow-up has too often failed to accomplish. Ultimately, including sterile processing sharps events in these incident reporting systems signals a real commitment to identifying root causes for these dangers, and provides a critical documentation trail for escalation of the issue when initial responses fail to effect a change.

There are too many contaminated sharps getting too close to our frontline technicians, with too little transparency into why it is continuing to happen. And just as importantly, without serious documentation, there is too little accountability over the entire process to hardwire lasting change and effectively protect our people. Incident reporting is a valuable tool to bring us closer to turning these sterile processing near misses into never-ever-happens events. Fire and brimstone not required.

What say you?


Feature articles exclusively for Ultra Clean Systems by Weston “Hank” Balch, BS, MDiv, CRCST, CER, CIS, CHL

Weapon of Mass Microbial Destruction * Professional Clean Freak * Podcast Host * Safety Addict * CS/SPD Consultant

Sign up to read Hank Balch’s biweekly feature in NewSplash!NewSplash is a free weekly digital newsletter dedicated to providing useful information to CS and IP professionals who strive to keep patient safety high.