The data on needlestick injuries is quite staggering. In the UK, percutaneous injuries involving hollowbore needles, the most commonly reported occupational exposures in the healthcare setting, have increased by 46% in recent years. Most incidents happen onwards. Of the eight million hospital workers in the US, 600,000–800,000 are expected to be injured by a needle/sharp each year.
The dangers or hazards associated with needlestick injuries are well understood in terms of transmissability of pathogens, HIV, hepatitis B and C, or in terms of chemical exposure through the handling of cytotoxic drugs or blood products. While hepatitis B carries the greater risk, at around 6–30%, pre-exposure immunisation drastically reduces this, while post-exposure treatment is also highly effective.
HIV, with the lower risk of around 0.3%, carries more severe consequences, though post-exposure prophylaxis is considered effective and is made available to healthcare workers.
A risk assessment can be invaluable in determining what steps to take to try to reduce the risk of these injuries. However, risk assessment is about much more than just assessing risk – something which medicine is already very good at.
Not explicit, but equally important, is that it is also about actively doing something to deal with the hazards. It is about mitigation and, where feasible, elimination.
The first step in a risk assessment is to construct a risk assessment matrix. This is an overview of a safety issue or, where hard scientific data exists, an accurate quantitative assessment of the dangers. In reality, such data is often lacking and the assessment is made on consensus – or even, when there is uncertainty or guesswork.
It is not always possible to pin down a hazard on a particular matrix with any precision. But the exercise can be worthwhile in estimating the relative risk and ensuring that high risk/severe category events are considered and prioritised.
RISK ASSESSMENT IN CLINICAL PRACTICE
Within healthcare, and particularly in clinical settings, adoption of the risk assessment model appears limited to specialist areas, such as psychiatric nursing. Here, risk assessment is used to evaluate the risks associated with behaviour and consider predictive indicators for violence and self-harm in patients.
The pattern seems to be that where risk assessment is applied successfully it is often with the patient as the central focus. While this reflects professional ethics and the constant search for improving standards of care, something we would all endorse, in the context of needlestick injuries a different mindset is required. The practitioner/clinician must now be central to the investigation, and the patient peripheral.
It is important to recognise that practitioners dealing with patients/clients are not usually the ones with purchasing power. This means that they are not in control of solutions to the hazards they identify. There are many solutions for needlestick injuries currently on the market – over 120 sharps safety devices. However, Dr Paul Grime has lamented the NHS purchasing imbalance between standard needles and syringes (at around £20m per year) compared with equivalent safety devices at £8m.
RISK ASSESSMENT PROCEDURES
The main burden of handling needles falls on nurses and junior doctors. However, these practitioners also need to be aware that the associated clinical waste is handled and disposed of by other hospital staff and council workers, and sharps incidents are recorded in this group.
Although core nursing values and procedures revolve around patient safety, there is little evidence of normal risk assessments on any subject being conducted at ward level or any nurse-patient interface. What form then, in a clinical setting, might a useful risk assessment framework take?
Several models and frameworks exist for a risk assessment procedure. These may appear bulky and impractical, mainly because they are generic, industry-oriented tools. The standard model places risk assessment within the larger context of risk management. This reflects the idea that risk assessment is something to be managed at many different levels within organisations.
The two main components within risk assessment are risk analysis and risk evaluation. Risk analysis is about defining the problem/activity, setting some boundaries, identifying the hazards, and estimating their probability. This process completes a risk matrix as far as possible.
A useful way to start this process is to consider consequences and ignore the probabilities. Considering the worst that can happen – say, a deep penetrating injury with an HIV-infected needle – sets the upper limit for this scale. Then, considering the least that can happen, such as a skin scratch with a clean ampoule, sets the lower limit.
Now consider what can come in between. If data is available it might be possible to construct the risk scale, or consider the hazards in relation to one another. Thus hep B > HIV, and sterile needle < hep B. Risk evaluation is a decision point as to what is a tolerable risk, and if the risk is not tolerable then what corrective/ preventive measures need to be in place?
The UK Health and Safety Executive (HSE) publishes generic guidelines on how its approach to risk assessment works. In doing so, the HSE accepts that it is not rocket science: it does not have to be complicated and it is often the case that the hazards and control measures are already well known.
In practice, every ward, department or clinic is unique, and each has a different architecture, layout, staff mix, workload and clinical practice. The HSE's five-step approach, conducted at this local level, can accommodate this variation.
Where prevention techniques (Step 3) may be formulated, the HSE offers some useful principles:
- Try a less risky option
- Prevent access to the hazard
- Organise work to reduce exposureto the hazard
- Issue personal protective equipment
- Provide welfare facilities
These principles tend to approximate and describe much of the effort that is already happening in needlestick injury prevention. For example, the concept of universal precautions, which treats all blood and body fluid as HIV-infected, regardless of the actual status, has been in place for a considerable time.
There is one more form of risk assessment that may be taken directly to the practitioner-patient interface. The concept is described as last-minute risk assessment. In industry it is used in high-risk operations where technicians are encouraged to pause and ask themselves a set of five questions at regular intervals:
- How can I hurt myself?
- How could I hurt somebody else?
- How could they hurt me?
- What do I need to do to make sure no one gets hurt?
- Am I doing it?
It is proposed that such a tool encourages a safety culture and highlights the individual's responsibility to promote that culture.
TOWARDS A RISK-FREE WORKPLACE
The Safer Needles Network sees formal risk assessment as one of the key areas in the broader strategy of creating a risk-free workplace together with a risk management system, improvements in training, and provision of safety devices.
What risk assessment is really about and why it is so important is that it creates a new context; it is a meeting place between professional carers and safety expertise. A problem-solving approach to needlestick injuries focuses on those who are actually getting hurt and challenges the status quo as to what is and is not acceptable risk.