Needle Sticks + Sharps: 'Activity and Intent' Drive Best Practices

March 28, 2017

A good Dynamic Work Design is built on four principles:

1. Reconcile activity and intent;
2. Connect the human chain through triggers and checks;
3. Structure problem solving and creativity;
4. Manage optimal challenge.

When Don and I first started to put these together, we thought the first principle was just a warm up and that the real action would come with principles two through four. We were wrong.

In December 2016, Don and I finished teaching our Dynamic Work Design course in MIT’s Executive MBA program. During class students must complete a work design project in their home organization and, at the end of the semester, we let them vote for their two favorite projects. This year’s winner showed how important reconciling activity and intent is to successful work.

Reducing Needle Sticks

Carlos Estrada is a surgeon a Boston’s Children’s Hospital (BCH). BCH’s safety data suggested that during day-to-day activity somebody is stuck with a sharp instrument (e.g., needle or a scalpel) about two times per week (90 to 100 times per year). “Sharps” injuries are painful and risk transferring an infection from the patient to the effected nurse or doctor. Due to that infection risk, after a “stick” the patient’s blood needs to be drawn and tested which requires parental consent, not something that already nervous parents really want to hear.Following good problem solving practice, Carlos focused his project on a subset of the problem, the number of times that a team member was stuck during a surgical procedure. His investigation revealed several significant departures from a regular reconciliation of activity and intent.

  • First, most people were not aware of the extent of the problem or the extent of the associated risks. Without regular feedback on performance, it’s not too surprising that people weren’t focused on injury reduction.
  • Second, most people were similarly unaware of best practices. With a little research, Carlos identified some best practices for sharps transfer. These included a simple communication protocol: “Sharp coming through!” This announcement tells people to take their hands out of the operating field—and to modify the way that needles and sutures are passed from doctors to nurses.  Holding the suture rather than the needle itself means that any incidental contact is much less likely to result in a puncture.
  • Third, he discovered variation in the way that the Operating Rooms (ORs) were staged. Though intrinsically safe, needles are available for several procedures and some ORs stocked the older, less safe versions. Each of these findings represents a failure to match intent and activity. Everybody agreed on the goal—no sticks—but nobody was getting regular updates on whether or not that goal was being met. Worse, people were also unclear on the activity set that would contribute to meeting that goal. Small changes to communication patterns, needle technique and provisioning offered significant potential.

With these findings in hand, Carlos made the following interventions. The data on sticks was tracked and reported regularly. Posters in the operating rooms reported the data, highlighted the risks associated with sticks, and provided guidance on best practices. Both intent and activity were now clear. The non-intrinsically safe needles were, where possible, removed from the operating rooms.

Following the changes, Carlos observed several surgeries and documented a 67% reduction in the number of unsafe transfers. In addition, he didn't observe a single stick injury. Only time will tell whether or not there will be a permanent improvement in safety, but reconciling intent and activity gave them a very good start.

As a side note, Carlos’ class included several other surgeons, three of whom are also revisiting their practices for transferring sharp objects.

Click here to view Carlos' A3.

Nelson Repenning

Nelson helps translate successful fieldwork into underlying principles with rigorous academic underpinnings for use in his work at MIT as well as by ShiftGear.

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