Identifying and Decreasing Sharps Injuries Through Root Cause Analysis in a Large Urban Hospital System

Details

• Personal Author:
  Hammond S ; Heaton K ; Montgomery AP ; Stallard C ; Trimble R
• Description:
  Background: Despite safety mandates and interventions, sharps injuries remain an occupational risk for registered nurses (RNs). Sharps and needlestick injuries increase the risk of exposure to blood-borne pathogens. Post-exposure direct and indirect costs of these percutaneous injuries have been estimated at about US$700 per incident. The goal of this quality improvement project was to identify root causes of sharps injuries for RNs at a large urban hospital system. Methods: A retrospective evaluation of sharps injuries sustained by RNs, identification epsication of themes or root causes, and the development of a fishbone diagram to sort the causes into categories to identify workable solutions were conducted. Fisher's exact tests were performed to identify association between variables and root causes. Findings: A total of 47 sharps injuries were reported from January 2020 through June 2020. Among sharps injuries sustained by nurses, 68.1% were among nurses 19 to 25 years of age and 57.4% reported job tenure of 1 to 2 years. There was a statistically significant association between root causes and tenure range, gender, and procedure type (p < .05) with moderate effect size (Cramer's V = 0.35-0.60). Technique also was a primary cause of sharps injuries for blood draw (77%), discontinuing line (75%), injection (46%), intravenous (IV) start (100%), and suturing (50%). Conclusions/Applications to Practice: Technique and patient behavior were primary root causes of sharps injuries in this study. More sharps injuries caused by technique occurred among nurses with job tenure of 1 to 10 years, female, blood draw, discontinuing line, injection, IV start, and suturing procedures. The root cause analysis identified tenure, technique, and behavior as potential root causes of sharps injuries specifically occurring most during blood draw and injections at a large urban hospital system. These findings will inform nurses, especially new nurses in the proper use of safety devices and behaviors to prevent injury. [Description provided by NIOSH]
• Subjects:
  Aging Behavior Blood Blood-Borne Pathogens Health Care Facilities Workforce And Services Health Personnel Hematologic Diseases Occupational Health Safety
• Keywords:
  Age Groups Author Keywords: Sharps Injuries Bloodborne Pathogens Control Injuries Medical Facilities Nurses Occupational Health And Safety Prevention Sharps Statistical Analysis

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• ISSN:
  2165-0799
• Document Type:
  Text
• Funding:
  Grant
• Genre:
  Journal Article
• Place as Subject:
  Alabama ; OSHA Region 4 ; OSHA Region 6 ; Texas
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  268-274
• Volume:
  71
• Issue:
  6
• NIOSHTIC Number:
  nn:20067667
• Citation:
  Workplace Health Saf 2023 Jun; 71(6):268-274
• Contact Point Address:
  Christopher Stallard, APRN, FNP-C, COHN-S, 3305 Timber Ridge Drive, San Angelo, TX 76904
• Email:
  cas.tx.rn@me.com
• Federal Fiscal Year:
  2023
• Performing Organization:
  University of Alabama at Birmingham
• Peer Reviewed:
  True
• Start Date:
  20050701
• Source Full Name:
  Workplace Health & Safety
• End Date:
  20270630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:f82ba7ffa43226edac11f3780c5466b3de816d37f7a2c745d2bb7e83aa62f61e93c6a1fc6632cae3f3dae8c72b2a6b5fcd65bf4ce953bfc61dcc35ba65bd3555
• Download URL:
  https://stacks.cdc.gov/view/cdc/229936/cdc_229936_DS1.pdf
• File Type:
  [PDF - 267.99 KB ]