|Year : 2014 | Volume
| Issue : 2 | Page : 122-126
Risk management to control needle stick injuries: Case report of Hazrate Zahra Hospital (2010-2012)
Masoud Ferdosi1, Mehrnoosh Torkan2, Shirin Abbasi3
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Environmental Health, Hazrat Zahra Hospital, Isfahan, Iran
3 Health Management, Faculty Research of Health and Medical Science, Research Institute of Shakhes Pajouh, Isfahan, Iran
|Date of Web Publication||18-Aug-2014|
PhD. Student of Health Management in Disaster, Faculty Research of Health and Medical Science, Research Institute of Shakhes Pajouh, Isfahan-8158-74351
Source of Support: None, Conflict of Interest: None
Needle stick injuries are one the most common types of injuries caused by infected sharps which threaten all staff employed at medical system. Prevention of needle stick injuries should be considered as one of the Hospital's strategic programs for authorities. The Hospital established the risk management in controlling needle stick injuries as preventive measures before injuries occurs. These measures include engineering controls, administrative controls, reviewing occupational hazards, proper corrective measures after injuries, calculation of manpower arrangement standard in high risk personnel, and improvement of work processes. This case report studies the performance of Hazrate Zahra Hospital of Isfahan during the years 2010-2012 in the field of needle stick risk management. Sampling was not performed and 71 employees injured were investigated. For reporting and collecting data, a questionnaire was used. Forms collected by the Infection Control Committee Administrator were examined and the results were analyzed using root cause analysis (RCA). The 3-year data were finally analyzed by T-test and Chi-square test using Statistical Package for the Social Sciences (SPSS) Software. Based on 3-year data, findings showed that there was a significant relation between employees' age and injuries. Also, there was a significant relationship between shift sequences and the number of injuries (P > 0.05). Findings showed that nurses and service personnel had the highest number of injuries with 22.5%. The results of the 3-year study show that the hospital has been able to reduce needle stick injuries by establishing strategies and have the risks under control.
Keywords: Hazrate Zahra Hospital, needle stick injury, risk management
|How to cite this article:|
Ferdosi M, Torkan M, Abbasi S. Risk management to control needle stick injuries: Case report of Hazrate Zahra Hospital (2010-2012). Int J Health Syst Disaster Manage 2014;2:122-6
|How to cite this URL:|
Ferdosi M, Torkan M, Abbasi S. Risk management to control needle stick injuries: Case report of Hazrate Zahra Hospital (2010-2012). Int J Health Syst Disaster Manage [serial online] 2014 [cited 2019 May 26];2:122-6. Available from: http://www.ijhsdm.org/text.asp?2014/2/2/122/139072
| Introduction|| |
Injections are one of the common prescriptions which may offer potential risks in the absence of standard methods.  Needle stick injuries are one the most common types of injuries caused by infected sharps which threaten all staff employed at medical system and have obtained great attention in the way to improve job safety for health sector employees. 
Medical and services staff have the highest risk of exposure to the hazards associated with sharps,  so that they might be exposed to the three major blood viruses (acquired immune deficiency syndrome, AIDS, hepatitis B, and hepatitis C) which can lead to chronic diseases. 
Needle stick injuries account for 80-90% of cases of infectious disease transmission to health care workers. Yet, it is hard to specify the real number of needle stick injuries, since even in the countries with good reporting system, not more than 30% of the needle stick injuries cases are reported. ,
Prospective studies show that the real number of needle stick cases is more than what reported in retrospective studies and the real number varies between 14-839 cases per each 1,000 staff per year in Brazil. In addition, during the injuries, employees experience great stresses and emotional trauma which are not measurable. 
Needle stick injuries reporting among clinical nurses was the case study that was done by Azadi. The results showed that 46% of the nurses have had a needle stick injury experience, but only 36% of these injuries were reported.  Another study in Iran indicated that there is a significant relationship between age, work experience, and knowledge of employees and needle stick injuries cases. 
According to a report in America, 37% of nurses reported to have kept themselves safe from needle stick injuries through precautionary measures.  The results of a study in 2008 in England included 840 needle stick injuries among 69 persons in a 2-year period of which only 6 persons have reported their injuries. Being busy with work, lack of time, and the follow-up difficulties were expressed as the main reasons for not reporting the injuries. 
In a study at a hospital in South Korea to examine the occupational injuries among nurses, needle stick was specified as the most common reason and more than half of the needles were infected. 
In 1992, Occupational Safety and Health Administration (OSHA) specified certain standards for workers exposed to the risks of needle stick. Among notable elements of the standard are development of control programs, training staff before injury, and assessment of injured employees through risk management. 
Considering the significant amount of harms and deaths following needle stick injuries and the lack of knowledge among personnel about preventive measures, it is necessary to study the number of needle stick cases for proper risk management and prospective planning. , Due to the importance of the issue and the ever increasing cases of blood-borne viral infections, risk management and systematic planning is essential to deal with this problem.
Center for Disease Control in America (CDC) estimates needle stick injuries to be about 500,000 cases annually. Thus, the awareness and usage of protective equipments are highly recommended. 
In 2010, the root cause analysis approach to risk management in Hazrate Zahra hospital in Isfahan was established and then a health record was formed for each hospital medical staff. Also, a reporting and tracking system for needle stick injuries was designed and implemented.
This research studies analyzed the quantity of needle stick injuries caused by sharps among employees of Hazrate Zahra hospital during the last 3 years, and also studies the corrective programs and their influence on reducing needle stick cases with a risk management approach.
| Materials and Methods|| |
This case report studies the performance of Hazrate Zahra hospital of Isfahan during the years 2010-2012 in the field of needle stick injuries risk management. Sampling was not performed and all 71 employees injured from 2010 were investigated.
For reporting and collecting data, information were used from a questionnaire that were extracted from related texts.
Questionnaire contained two parts of demographic characteristics' questions (age, gender, the unit, job, the shift type) and questions based on research objectives such as cause of injury, the instrument that has caused the injury, a history of vaccination against hepatitis, and corrective measures after the injury. In order to determine the validity and reliability questionnaire distributed for ten cases of infection disease, specialists were employed in medical science university of Esfahan, their opinions collected, and correction actions done. In any case of injury report, some necessary actions should be undertaken such as completion of form, medical examination by an infection specialist, control measures to prevent infection, reviewing the history of vaccination, and other required measures in accordance with the officially notified protocol of the Department of Health. Then, forms collected by the Infection Control Committee Administrator were examined and the results were analyzed using root cause analysis (RCA) approach and Fishbone Technique.
At the end of each year based on RCA results, corrective actions and preventive measures were taken to be implemented over the next year. The 3-year data were finally analyzed by T-test and Chi-square because the data distribution was normal. Test was done using SPSS software. A type 1 error of 5% was considered for the tests (α = 5%). For privacy principles, the results were announced without mentioning names.
| Results|| |
Based on 3-year data, the average age of needle stick injured employees was 31.8 years with a standard deviation of 7.5. The lowest age was 22 years and the highest was 55 years old. Findings showed that there was a significant relation between employees' age and injuries. Findings about the section of employment showed that the highest numbers of injuries were related to employees of operation room and laboratory with 31% and 14%, respectively. Also, the least numbers were related to the employees of laundry and clinic (1.4%). Differences in the number of injuries among morning, afternoon and evening shifts were statistically significant. Also, there was a significant relationship between shift sequences and the number of injuries (P > 0.05).
By focusing on the year of the injuries of the employees, it can be seen that the highest rate of injuries is related to the year 2011 with 51%. Also, the sequence of the employees' shifts showed that 7% of injured employees were in consecutive shifts when injured which indicated a significant relationship between injuries and shift sequences. Findings showed that nurses and service personnel had the highest number of injuries with 22.5%. Important findings are shown in [Table 1].
Syringe needles were the main injury cause among other instruments with 46.5%. Using angiocath, contact with biological fluids of body, injuries caused by blades, and using suture needles and other sharps accounted for the rest of injuries with 15.6, 14, 10, and 13.9%, respectively.
For root causes found at the end of 2010 and 2011, two series of corrective actions and preventive measures were considered to be the work base in subsequent year [Table 2].
|Table 2: Root cause analysis, corrective, and preventive actions in the years 2010 and 2011|
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Roots found in the end of 2010 and the end of 2011 showed that the two series of corrective actions and preventive measures were considered in subsequent work was based. Importance of these measures is shown in the table below [Table 2].
Causes of injuries are shown in [Figure 1]. Findings showed that personnel experienced the highest rate of injuries during phlebotomy (17 cases) and operations (16 cases). The least injury cases were related to washing surgical sets. Results showed significant differences between the cause of injury and continuity of working shifts of employees.
| Discussion|| |
Results showed that 37% of health care workers have experienced needle stick injuries during the study period. Women had the highest rate of injuries, which was in agreement with the results of the studies conducted by Azadi. 
More than half of the personnel were injured in morning indicating the influence of workload. According to Pooral'ajal, of the whole 240 cases of having contact with blood, the highest rate of was related to morning shifts.  Studies conducted by Smith showed that systematic work shifts work such as morning shifts, which are associated with increased exhaustion and stress may result to the increased number of needle stick injuries among nurses which is consistent with the current studies. 
According to results, most of the injuries are related to operation room. Operation room is a unique environment for an individual to encounter within juries where the medical team exchange sharps infected to the patients' blood in a small space. Besides that, the operation room environment is usually a closed stressful environment where staff have to deal a lot with sharps and are probable to encounter with blood and other infected liquids. Studies of Kazemiin Khanevadeh hospital in Tehran also confirmed that the highest percentage of needle stick injuries occurred among the operating room staff  which is in agreement with the results of the current study. Jagger suggests that where critical treatments are being performed for patients, the risks of the injuries are more likely to arise. 
The influence of shift sequences was also studied in this research. Results showed that only about 10% of employees who have worked on two consecutive shifts have been injured. Studies of Ilhan showed that working to more than 8 hours in a day is a contributing factor in the increasing number of needle stick injuries. 
Nurses and service workers were the highest injured employees among the others. Figures indicate the necessity to consider the risk of infectious viral diseases among the two groups. Thus, following the standard number of nurse and service workers for inpatients, their logical distribution, development of retraining programs, as well as providing a calm working environment has a great importance on keeping the employees safe. Results of a study in America showed the highest needle stick injuries was related to nursing staff.  According to Goob, 35% of the total needle stick injuries were related to the nursing staff being consistent with the current results. 
Considering the high vaccination coverage among staff in the research due to the health level enhancements, increased facilities and capabilities, and the increased importance of application of ways to fight hepatitis B, the risk of infectious diseases is minimized. In a study in Saudi Arabia, 82% of staff were vaccinated against infectious diseases.  While in a study by Mojib, only 36% of staff were vaccinated, which is inconsistent with the current study. 
Syringe needles were the main cause of injuries according to current study with 46.5%, which is consistent with the results obtained by Heydari and Rakhshani; while in the Bakaeen study, suture injuries were dominant. ,, According to [Figure 1], the most important cause leading to injury is Phlebotomy with 24% and the lowest percent is related to washing surgical set with 1.4%.
According to Aiken, most needle injuries happened during syringe needles recap. Nowadays, this factor is not common due to emphasis on not recapping the needles as the current study shows.  Results obtained in this study are consistent with a study conducted in India on the injuries during Phlebotomy. 
Results showed that a high percentage of the injuries were due to lack of staff knowledge of the injection standards. The main intervention measures in the hospital were improvement activities related to the reception and phlebotomy and training of in danger staff. In a study on 847 medical staff, the high workload, haste, and lack of knowledge were the most important predisposing factors for injuries in the employees' point of view. 
Absence of written instructions was another cause of injury in some sections. Major interventions in this regard were shaping of policy and procedures for appropriate administration and controlling working processes through weekly visits. According to Chambers, the use of standard medical equipment and shaping local regulations are have a great influence on reduced staff injuries. 
| Conclusions|| |
According to the results, prevention of needle stick injuries as one of the strategic programs of the hospitals should be considered by the authorities. Thus, hospital authorities performed risk management in controlling needle stick injuries in the form of preventive measures and corrective actions. Preventive measures prior to injuries include: Engineering controls (use of safe medical equipments and tools such as standard gloves, glasses, etc); administrative controls include: Retraining classes for safety and staff awareness particularly operating room staff, nursing staff, and service workers, development of working instructions, managerial visits, and prevention of sharps exchange; medical engineering advances including the development of safe needles and safe disposal of needles, personnel vaccination, monitoring of sharp wastes disposal, review of work risks such as recapping syringe needles; and corrective actions include: Development of action plans to reduce needle stack with improved engineering controls in equipment, establishment of hazard reporting process and performing after injuries corrective measures such as washing injury position with soap and water, in time documenting of injuries and determination of the source of disease through tests of hepatitis B and C, calculation of standard ordering of the high risk personnel, and improved job processes.
| References|| |
|1.||Ferreiro RB, Sepkowitz KA. Management of needle stick injuries. Clin Obstet Gynecol 2001;44:276-88. |
|2.||Vose JG, McAdara-Berkowitz J. Reducing scalpel injuries in the operating room. AORN J 2009;90:867-72. |
|3.||Tenstaedt RL, Payne S, Roberts RJ, Russell IT, Russell D, Edwards RT. Needle-stick injuries in primary care in Wales. J Public Health (Oxf) 2007;29:434-40. |
|4.||Rele M, Mathur M, Turbadkar D. Risk of needle stick injuries in health care workers - A report. Indian J Med Microbiol 2002;20:206-7. |
|5.||Gail D. Nurses at risk: A call to nurse to protect themselves. AJN 1999;99:44. |
|6.||Au E, Gossage JA, Bailey SR. The reporting of needle stick injuries sustained in theater by surgeons: Are we under reporting? J Hosp Infect 2008;70:66-70. |
|7.||Elucir Gir RK, Canini SR. Accidents with biological material among undergraduate nursing students in a public Brazilian university. Braz J Infect Dis 2004;8:18-24. |
|8.||Azadi A, Anoosheh M. Needle stick injuries reporting among clinical nurses. Iran J Nurs 2007;49:7-14. |
|9.||Mohamd Nejad S, Esfand Bod M. Injuries of sinking sharp objects and reporting rates among EMS nurses . Iranian Journal of Infectious Diseases ISSN 1680-0192. 2007: volume 15, No 48 ,Pp 49-54 . available from: HYPERLINK "http://www.IICCOM.ORG/JOURNAL.ASP" \t "_blank" WWW.IICCOM.ORG/JOURNAL.ASP. |
|10.||Lin Yang and Barbara Mullan, "Reducing Needle Stick Injuries in Healthcare Occupations: An Integrative Review of the Literature," ISRN Nursing, vol. 2011, Article ID 315432, 11 pages, 2011. doi:10.5402/2011/315432. |
|11.||Smith DK, Myoung-Ae C. Epidemiology of needle stick and sharps injuries among professional Korean nurses. J Prof Nurs 2006;22:359-66. |
|12.||Wolf BL, Marks A, Fahrenholz JM. Accidental needle sticks, the Occupational Safety and Health Administration, and the Fallacy of public policy. Source Department of Medicine, Vanderbilt University, Nashville, Tennessee 37205, USA. Wolfatthelair @ comcast. Net. Department of Medicine, Vanderbilt University, Nashville, Tennessee 37205, USA. Wolfatthelair @ comcast. Net. 2006;97:52-4. |
|13.||Bonni R, Leslie G. Evaluation of interventions to prevent needle stick injuries in health care. Am J Prev Med 2000;18:90-8. |
|14.||Smith MP, Berry AJ. Hazard of small gouge needles. J Infect 2000;82:310-1. |
|15.||Centers for Disease Control and Prevention (CDC) (2004 th ). Workbook for designing, Implementing and evaluating a sharps injury prevention program. Available from: http://www. cdc. gov/Sharpssafety/index. html [Last retrieved 2006 Mar 31]. |
|16.||Azadi A, Anousheh M. Infected needle stick injuries and reporting rate among clinical nurses. Iran J Nurs 1386;49. |
|17.||Pooral′ajal J, Haddadi A, Nazila A, Mohammad K. Studying the job encounter frequency with blood and other potential infected material and related factors among employees of medical centers in city Hamadan. Iran J Infect Trop. 2007;20:7-14. |
|18.||Smith DR, Mihashi M, Adachi Y, Nakashima Y, Ishitake T. Epidemiology of needle stick and sharps injuries among nurses in a Japanese teaching hospital. J Hosp Infect 2006;64:44-9. |
|19.||Galougahi MH. Evaluation of needle stick injuries among nurses of Khanevadeh Hospital in Tehran. Iran J Nurs Midwifery Res 2010;15:172-7. |
|20.||Jagger J, Perry J. Cutting sharps risks in ICUs and CCUs. Nursing 2005;17. |
|21.||Ilhan MN, Durukan E, Aras E, Türkçüoðlu S, Aygün R. Long working hours increase the risk of sharp and needle stick injury in nurses: The need for new policy implication. J Adv Nurs 2006;56:563-8. |
|22.||English JF. Reported hospital needle stick injuries in relation to knowledge/skill, design, and management problems. Infection Control and Hospital Epidemiology 1992;13:259-64. |
|23.||Goob TC, Yamada SM, Newman RE, Cashman TM. Blood borne exposures at a United States Army medical center. Appl Occup Environ Hygiene 1999;14:20-5. |
|24.||Jahan S. Epidemiology of needle stick injuries among health care workers in secondary care hospital Saudi Arabia. Ann Saudi Med 2005;25:233-8. |
|25.||Mujeeb SA, Khatri Y, Khanani R. Frequency of parenteral exposure and prevalence of HBV, HCV and HIV among operation room personnel. J Hosp Infect 1998;38:133-7. |
|26.||Heidari M, Shahbazi S. The frequency of injuries by sharps infected by patients′ blood among personnel of operation room in Hospitals of Borujen and Lordegan. J Coll Nurs Midwifery Paramed Rafsanjan 1389, YearV, Number 1 st and 2 nd , fall and winter 89. p 34. |
|27.||Rakhshani F, Heydari M, Barati B. Prevalence rates and causes of needle stick injuries caused by sharps and the performance of employees of medical centers of Zahedan University of Medical Sciences. Iran J Epidemiol 1387, Period 4, Issues 3,4. 87-91. |
|28.||Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, Izard D, et al. Epidemiology of exposure to blood borne pathogens on a surgical service. Am J Surg 2006;192:e18-21. |
|29.||Aiken L, Klocinski J, Sloane D. Hospital nurses′ occupational exposure to blood: Prospective, retrospective, and institutional reports. Am J Public Health 1997;87:103-7. |
|30.||Jayanth ST, Kirupakarn H, Brahmadanthan KN, Gnanarg L, Kang G. Needle stick injuries in a tertiary care hospital. Indian J Med Microbial 2009;27:44-7. |
|31.||Vahedi MS, Ahsan B, Ardalan M, Shahsavari S. Study of the prevalence rate, causes and performance of employees of medical centers of Kurdistan University of Medical Sciences regarding injuries caused by infected sharps in 1383, Scientific Journal of Kurdistan University of Medical Sciences, Period XI, Summer 1385, Period 11, Issue 2, 43-50. |
|32.||Implement Sci 2013; 8: 9, Published online 2013 January 22. Evaluating the implementation of health and safety innovations under a regulatory context: A collective case study of Ontario′s safer needle regulation. |
[Table 1], [Table 2]