What do you do when your OR team follows sharps safety rules, yet still gets stuck by suture needles and sliced by scalpels? That was the frustrating conundrum facing the administrators at a metro hospital in Council Bluffs, Iowa. Despite their best efforts, they saw no obvious patterns related to sharps-related injuries in terms of who was getting injured and what procedures were involved.

That was where I came in. As an ergonomist, I brought a different perspective to the challenge. After all, these injuries were happening to people who were experts in dealing with sharp instruments and needles. It wasn't that they didn't know how to handle a needle or how to use neutral zones when passing sharp instruments to each other. There had to be some other considerations that people weren't taking fully into account. When I began my observations, 2 things that are obvious to you jumped out at me:

• The OR staff was dealing with a very small operative field.
• A lot of hands and powerful instruments were moving in and out of that small space.

I remember thinking that if this had been an industrial setting (where a lot of my ergonomics training took place), and I saw sharp, powerful instruments in a small space close to people's hands, we'd install machine guards, insist people wear cut-resistant gloves and probably implement other safety measures as well.

In fact, cut-resistant gloves were the first thing I recommended. No good. They turned out to be too thick and heavy, and the staff said they compromised manual dexterity and tactile feedback. We also thought about trying to develop a shield to protect people's hands. But that, too, was a non-starter. They didn't want anything else clogging up the operative field.

Incidentally, double-gloving with standard surgical gloves did help prevent skin from being pierced by needlestick pokes in incidents that we classified as near-misses. And they didn't inhibit tactile feedback or dexterity. Many needlestick injuries were superficial, so double-gloving, which is among AORN's guidelines for needlestick-injury prevention, was one of the measures we adopted as a best practice. We should always be on the lookout for innovations and safer designs in terms of needles and sharps. But we needed to dig deeper to get to the root of the problem.

Fatigue and pain

I realized that just training somebody on how to hold a scalpel or how to handle a suture needle — the things we consider standard — aren't enough. You have to look at all the different components involved, including teamwork, the cognitive aspect and the physical challenges associated with surgery. These aspects are interrelated and each aspect affects the others.

Surgery can be extremely physically demanding. Take, for example, a surgical tech who's assisting with an orthopedic case. She might have to hold a retractor for 2 hours or more to help keep the operative field open. But she can't be in the surgeon's way while she does it, so she may have to stand off to the side with her arm fully extended.

That's an ideal scenario for developing localized fatigue, and eventually pain. When you're in pain, you're distracted. It saps your attentional resources and creates the potential for errors and injuries. The technicians were very forthcoming about it. They felt it in their shoulders, their necks, their arms, their hands, their wrists — just about everywhere.

The same was true of surgeons. Some complained about neck pain after long procedures, caused by sustained head and neck postures, particularly when the OR table height or the overhead monitors weren't properly adjusted relative to their eye level. The point is that fatigue and pain can force us to let our guard down. When you're distracted, it's easy to take your eyes off a moving suture needle or to put your hands in the wrong place at the wrong time.

Listen to your body

Fortunately, there are things you can do to reduce the risk factor caused by fatigue. We explained how small things could interrupt the fatigue process whenever they got the opportunity.

We know from ergonomics studies in industry that certain movements and certain postures are more stressful for joints. The more you deviate from neutral positions, the quicker the joint fatigues. So, for example, the farther away from your body you stretch out your arm, the more tense the muscles become. If you bring your arm closer to your center of gravity, the muscles automatically relax more. In an OR setting, you might not be able to bring your whole arm close to your center of gravity, but if you can bring your elbow a little closer, you begin to change the dynamics.

Occasionally contracting and relaxing those muscle groups also helps, as does changing your position whenever possible, and not assuming more awkward postures than necessary.

The body doesn't ask for much, but many times we don't even give it that. It's doing its job when it gives you feedback in the form of pain. Either it doesn't like your posture and wants you to change it, or it wants some fresh blood and saturation to go to that region.

People who work in ORs are experts at what they're doing, so they're perfectly capable of using their best judgment to make these slight adjustments. A tech may have to hold a retractor in an awkward position to get the job accomplished, but people often bend and twist more than they have to. It's surprisingly easy to use more force than necessary to accomplish a given job. And of course, if there's an opportunity for somebody else to relieve the tech who's been holding the retractor for a long time, that, too, can make a huge difference.

The cognitive piece

Cognitive overload is also a factor. Accidents are more likely if people are talking about irrelevant things, or simply talking too much. Safety requires concentration and the ability to focus fully on what's going on at the moment.

At a teaching hospital, I concentrated even more on the cognitive aspect, because of the presence of students and residents. Experts may be able to function on autopilot, but for novices, everything is new. When you're working with residents and students, you need to be careful not to overload them. For example, if music was going to be played in the OR, I encouraged the teams to stick to instrumentals. Expert surgeons might be able to listen to their favorite songs and stay focused, but because of the way auditory information enters the brain, if residents and students hear words, they're not going to be able to shut them out. And that's going to take up some of the resources they need to fully pay attention.

We emphasized the importance of silence or task-related communication only, during critical phases. Oral feedback was also key. Personnel needed to warn each other if they saw someone's hand getting too close to a moving needle.

I also noticed that closing seemed to be accompanied by significantly more opportunities for cognitive overload and distractions. Everyone is relieved that the surgery is over, the music comes on and the team starts talking, often about things that aren't relevant to the immediate tasks.

Leadership is vital

Real life is multifactorial, so our analysis and solutions had to be multifactorial, too. We needed to address the physical, cognitive and psychosocial components to get injuries under control.

And we also needed something else: the full support of leadership and the OR staff. I've been an ergonomist for more than 20 years, and I know that when I do ergonomics training in factories, the only way to make it succeed is to make sure the team leads are very well trained and that they get buy-in from the line staff.

I had great teams working with me at both hospitals and actively participating in the process improvement studies. At the teaching hospital, I had 2 surgeons working with me as co-investigators, as well as many of the core OR team personnel participating in the study. Compliance was excellent. I trained the surgical technicians and nurses, and one of the surgeons trained the residents and students because I knew he would have more credibility with them.

In the end, a quick and temporary fix wouldn't do. We needed to change the culture. To accomplish that, we needed supervisors who would reinforce the training and staff who bought into the safer practices. That's what they did, and that's how we brought about real change.

Incidentally, the surgery teams had made it clear that the training I developed had to be efficient. They couldn't afford to spend hours in a classroom. The improvement came about with just 2 15-minute training modules.

Within a year, the hospital achieved an 86% decrease in injuries from sharps and needlesticks. Now, several years later, it continues to rank among the best hospitals at preventing such injuries. OSM