Every year, more than half a million health care workers suffer sharps injuries. The wounds can range from pinpricks to deep cuts, but the chain of events that follows is always the same - the reporting, the reviews, the follow-up testing, treatments, and time loss. With it comes the emotional and economic toll, for both the health care facility and the victim, of dealing with possible illness or death…due to one tiny mistake.

I endured this ordeal back in the 1980s, when I was severely cut with a scalpel while performing a hysterectomy. After interviewing the patient in the recovery room, I was shocked and surprised to learn of some risk factors in her husband's lifestyle. Those factors placed both of us at risk, and we had to be tested for HIV.

Although the tests were negative, that event spurred me to find, evaluate and disseminate techniques for making the OR a safer workplace. In this article, I'll describe some of the precautions and preventive strategies I've learned and use in the OR every day.

How Sharps Injuries Occur
What causes them:
The vast majority of sharps injuries in the OR are due to scalpels and suture needles. But there are a host of other devices that may cause injury, including wire sutures, hollow injection needles, guide wires, stylets, drain trocars, broken medication vials, and almost anything else with a sharp edge or pointed tip.

Where they happen:
The thumb and index finger of the non-dominant hand are most likely to be injured, followed by the middle finger, other fingers, palm, and back of the hand. The non-dominant hand is a likely target, since it is often used to reposition and reach for needles, hold tissue that is being cut or sutured, or used as a retractor to protect adjacent viscera during cutting or suturing. Injuries are most likely to happen during longer procedures, procedures associated with increased blood loss, and procedures where large numbers of personnel work in a confined space.

How they happen:
Many seemingly innocuous actions can lead to injury, including:

Transfer between personnel:
Most accidents happen when someone tries to transfer an instrument to another worker. One study of scalpel blade injuries showed that 61 percent were inflicted by the user on assistants, mostly during equipment transfer. Another similar study of suturing injuries showed that about a quarter of them occurred during a transfer.

Assembly and disassembly of sharps: Mounting or repositioning the needle in the needle holder, or mounting the scalpel blade on the handle, can often lead to injury.

During use of the sharp: Preventable injury may occur during scalpel use or suturing when surgeons or staff use their fingers as a backstop or guide; when they hold tissue during suturing; when they sew toward the fingers of the surgeon or assistant; when the surgeons or staff protect adjacent structures with their hands while suturing; when they employ manual tissue retraction or wound exposure; when they tie off sutures with the needle attached; or when they leave needles on the surgical field or hold them in their hands while tying sutures.

During disposal: Many health care workers recap used needles, which can easily lead to injury. Injuries can also occur if a sharps disposal container is overfilled or improperly positioned, if the opening is too small for the intended devices, or access to the opening is obstructed.

Seven Ways to Prevent Sharps Injuries

1. Choose effective personal and protective equipment
Eye and face protection:
For maximum protection, use plastic face shields to protect the eyes, nose, and mouth. If you find face shields too cumbersome, try goggles or eyeglasses with top and side protection or a face mask with an integrated clear plastic eye shield. To keep face shields and masks from fogging, choose an anti-fog mask, ensure that the mask fits the contour of the face, and keep the room cool to avoid perspiration.

Surgical gowns: Choose gowns with length and permeability characteristics to match the anticipated risk of procedures. Remember that the weak link in all surgical gowns is the glove-gown interface; the woven fabric on the sleeve cuff can act as a wick if blood seeps under the top of the glove. Possible solutions to this problem include using sleeve reinforcements, wrapping sterilized rubber bands around the cuffs, or putting on the first layer of gloves before the gown. I prefer extended cuff gloves.

Surgical Gloves:
Numerous studies comparing single and double gloving show that you can greatly reduce blood contamination on the hands by wearing two pairs of gloves. For this reason, I suggest that you make double gloving routine. I've found it effective to always wear a medium-weight glove under a regular-weight glove, both of the same size.

2. Find alternatives to sharps
The best sharp alternative available, I've found, is the blunt-tipped suture needle. A recent CDC study found that blunt needles caused no percutaneous injuries, reduced the incidence of blood contacts resulting from glove perforations by eightfold, and were well accepted by surgeons once they were educated in their use. You can use blunt needles in many outpatient procedures, particularly in general surgical and gynecological procedures. In addition to being safer, blunt needles may also protect the patient by creating a less traumatic path through tissue; sharp needles are more likely to lacerate small blood vessels. Remember that needles vary greatly in bluntness; what kind you use will depend on the density of the tissue.

Other blunt alternatives include staples for skin closure, scissors with rounded tips, non-penetrating towel clips, blunt retractors, synthetic sutures in place of wires, and hemostatic clips. Alternatives to scalpels include scissors and cautery.

3. Use safer sharps
If you must use sharps, find the safest kind available. For example, use scalpels with rounded-tip blades, and select disposable varieties or varieties with automatically retracting blades to eliminate the risk associated with assembly or disassembly. Eschew straight suture needles in favor of curved needles with a needle holder.

4. Pass and handle sharps safely
Instead of passing sharps directly from surgeon to staff and vice-versa, designate a container as a neutral or safe zone, where the team can place and retrieve sharps rather than pass them hand to hand. The container should be large enough to contain the sharps, not easy to tip over, and easily mobile. Don't use a kidney basin for the neutral zone - items are hard to pick up, and the basins tend to tip over.

5. Adopt safe habits
Encourage all members of the surgical team to speak up when they perceive a real or potential hazard. Train your team to keep their hands away from the incision while the surgeon is cutting or suturing, avoid leaning over the incision when cutting or suturing is taking place, and avoid unnecessary or repetitive movements, such as reflex sponging of the tissue when the surgeon is cutting.

6. Dispose of sharps safely
Make sure that all sharps disposal containers are puncture proof, have an opening of adequate size to accept the sharps used in the procedure, and have a readily visible "full" line, indicating when the container should be replaced. Place the container as close as possible to the surgical site, ideally within arms' reach, so the caregiver can see and reach it easily.

7. Evaluate new safety devices carefully and completely
Involve all potential users on the surgical team, as well as infection control and risk management specialists, when evaluating new products. Take advantage of training materials from industry representatives and distributors to educate your entire team in the proper use of new safety devices.

My staff and I use all of these techniques every time we step into the OR, and because of them, we all trust each other completely and enjoy operating more. I urge all of you to take the same steps. Your patients will be better protected, your staff will be safer, and the quality of care in your facility will increase immeasurably.