The EMS Contrarian by Bryan E. Bledsoe

Danger at the Door

I am a proponent of EMS personnel having a more independent practice. The days of calling “Rampart Hospital” for an order of “D5W TKO” is a thing of the past. I truly feel that most of our educational programs are strong enough to support independent decision-making by EMTs and paramedics. But it is important to remember that independent decision-making also requires one to take responsibility for their decision and actions. This is somewhat of a new concept for EMS personnel.

One area where independent decision-making has been delegated to EMS personnel is selective spinal motion restriction (spinal immobilization). There is an excellent body of research that shows that the application of an established protocol allows EMS personnel to accurately and safely determine which patients should be immobilized and which should not. We have added it to our textbooks and many EMS systems have adopted it.

Spinal immobilization is uncomfortable and can cause complications in certain patients. Thus, like any other skill or procedure, it should be used when the patient stands to benefit from it. That is, when the patient has the possibility of a spinal injury. Certainly, with spinal injuries, we want to be extremely cautious and should have a high index of suspicion. Likewise, we don’t want to subject a patient to unnecessary discomfort and pain.

Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.

Now, let’s look at this a little more closely. In the system where 13.5 percent of patients with spinal injury were not immobilized, a policy was in place to allow EMS personnel to determine who should be immobilized and who should not. The premise is that all patients should be immobilized unless they meet the criteria to bypass immobilization. The protocol requires that EMS personnel complete a structured, standardized exam (e.g. altered LOC, spinal pain or tenderness, neuro deficit, distracting injury). If the patient meets any of the established criteria, they must be immobilized.

So in 13.5 percent of the cases, EMS personnel performed an exam and came to the conclusion that immobilization was not necessary. Thus, from a negligence standpoint, this was an act of commission and not an act of omission. A jury would probably look more unfavorably on an act of commission. In reality, what this tells me is that some EMS personnel are NOT properly applying the protocol or applying it selectively. The protocol only works if applied in a standardized fashion—the same, each time and objectively—to ALL trauma patients.

EMS personnel want more autonomy, but autonomy requires integrity. Integrity is what you do when nobody is looking. Medicine requires an extremely high degree of integrity; shortcuts in medicine can harm people. In emergency medicine, we assume a patient has a severe injury until proven otherwise. It is the only safe way to approach things in a short period of time. This same adage holds true in EMS.

Quality monitoring in EMS should detect issues such as this — this is how the trauma system detailed above discovered the 13.5 percent miss rate — but quality monitoring must be applied uniformly and EMS personnel must be given the results on a regular and constructive basis. Personnel who are taking short cuts and making clinical assumptions should be counseled. This spinal immobilization trend may well turn out to be like the trend we saw in the late 1990s with unrecognized esophageal intubations. It cannot be tolerated.

There are many of us working to improve EMS. More pay and more independence are needed, but these come with the associated responsibilities. It is frustrating in that every time we make some progress, EMS finds a way to shoot itself in the foot and set things back. Let me close with this: Every time you are using a selective immobilization protocol, assume that the patient is a member of your immediate family. Apply the protocol systematically and uniformly. If in doubt, immobilize. Please, let’s not take another step backwards.

" src="http://www.ems1.com/data/img/btn_go.gif" align="absmiddle" border="0" height="16" width="16"> Related Resource: Spinal Assessment Protocol — Maine EMS

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Bryan E. Bledsoe, DO, FACEP, EMT-P is an emergency physician, paramedic and EMS educator. Dr. Bledsoe is the principal author of the Brady paramedic textbooks and others. He has more than 20 years publishing experience and has more than 900,000 books in print and has written more than 400 articles. He is a prolific writer, popular lecturer, and EMS researcher. Dr. Bledsoe is currently developing a distributive educational program for initial EMS education through the University of Nevada Las Vegas and online continuing education through Paramedic.com. Dr. Bledsoe maintains residences in Midlothian, Texas and Las Vegas, Nev. To contact Dr. Bledsoe, email bbledsoe@earthlink.net.

Four Key 'Points to Ponder' for Your Safety

Safety Zone
Rick Patrick
2008 Oct 19

Point I
Safety is personal. Regardless of the tools and training provided by your organization and/or employer, only you can make the choice of being safe. Where do you place safety in the scope of your daily duties? Nothing super cedes your safety -- NOTHING!

Point II
Seatbelts work. Do you wear your seat belt? Do you wear it when responding to emergency incidents in the fire truck, ambulance or other vehicle? Do you wear it in the back of the ambulance? If you answered no to any of these; ask yourself why? Could I have done and should I do anything different? Every time you don't wear a seat belt equates to a near-miss situation -- every time.

Point III
Personal protective equipment (PPE) must be provided by emergency service organizations for all applicable tasks warranting a risk of injury.

EMS providers performing tasks indicative of the risk of injury (extrication, patient removal from a vehicle, rescue activities in general, risk of fire, etc.) and functioning in any capacity in the danger zone of an incident, such as motor vehicle collisions, should be protected by wearing PPE. This includes coats, pants, helmets, gloves, eye protection and protective foot wear. Nothing super cedes personal safety -- NOTHING!

Point IV
Responding safely, functioning safely at the scene and returning safely are essential for everyone's safety on every incident … period.

Read more articles by Rick Patrick

Richard W. Patrick
Richard W. Patrick, MS, CFO, EMT-P, CHS III, FF, is the retired Deputy Fire Chief of Estero Fire Rescue District in Estero, Fla. He has more than 29 years' experience in emergency services. He's the former Director of EMS Programs and Emergency Service Initiatives for VFIS, a division of Glatfelter Insurance Group, York, Pa., where he remains as a consultant. Rick is a nationally known leader, educator, lecturer, author, speaker and consultant in EMS

UK woman threatens paramedic with AIDS

By Emily-Ann Elliott The Argus

SOUTH EAST COAST, UK — A woman with hepatitis C smeared blood on a paramedic's face and told him he would be infected with AIDS, the South East Coast Ambulance Service NHS Trust has revealed.

The patient was given a two-month custodial sentence for the offence which happened in Hove in September as the paramedic attempted to treat her.

The health threat to the paramedic is believed to be negligible, but the prosecution has been highlighted as part of this year's NHS Security Awareness Month.

The service recorded 69 assaults against its staff between April 2007 and April 2008 and has warned it takes a zero-tolerance policy towards violence and abuse against its staff.

Other prosecutions include a 17-year-old male who was given a three-month referral and ordered to pay £50 compensation after biting and bruising a paramedic in Uckfield in August 2008 and a man was recently jailed for four years for possession of an imitation firearm with intent to cause fear of unlawful violence after threatening a paramedic in Worthing in September 2005.

Paul Sutton, the service's chief executive, said: "We want to ensure that our staff can provide the care they need to, and patients can receive this, in an environment that is safe and secure.
"It's simply not acceptable that staff perceive abusive behaviour towards them as just a part of the job. They deserve to be able to serve their local communities in safety."

This month security specialists will visit ambulance staff to educate them on what to do if they become a victim of violence and the options available to them when dealing with abusive people.
David Dixon, South East Coast Ambulance's security management specialist, said: "We will be working throughout Security Awareness Month and beyond to raise awareness among our staff so they understand they don't have to accept abusive and violent behaviour.

"We have achieved a number of successful prosecutions this year by working with the police and Crown Prosecution Service.

"We also want staff to know that there are alternative measures available to us such as private prosecutions, civil action and ASBOs which can be taken against those who threaten them."

Delegate Specifically

Delegate specific tasks to specific people using appropriate supervision.

So this can't be simply, "keep an eye on Mr. Smith in Room 12." Delegation has to be specific. So we have to define parameters that we're assessing for. We have to define accountability and measurement of those parameters to a specific person who is able to manage that task. In other words, if you have an aide that is going to be taking vital signs you don't want to tell them, "can you please take vital signs on Mr. Smith every 15 minutes because I need to know if she has a transfusion reaction?" Instead you need to say to her, "please take vital signs on Mr. Smith every 15 minutes, I'm looking for a transfusion reaction and I will check the vital signs that you get every 15 minutes to make sure that they remain in the normal range".

You don't want to give a specific parameter to somebody who doesn't know how to interpret that information. So for example, you couldn't tell the aide, "come back and tell me if her temperature goes up." Okay, well her temperature didn't go up but she's hypotensive and tachycardic; you see, that wasn't a good delegation. We need to define specific accountability and specific parameters. By doing so you will decrease your chance of liability, you'll increase accountability for the things that happen with your patients, and you will improve outcomes.

Best wishes,

David W. Woodruff, MSN, RN-BC, CNS, CEN
President, Ed4Nurses, Inc.

Hepatitis C

Hepatitis C

Hepatitis C virus is the most common chronic blood borne infection in the United States with an estimated 4.1 million American infected. World-wide there is an estimated 170 million persons chronically infected. The number of new infections per year has declined from 240,000 in the 1980s to 26,000 in 2004.

Potential risk factors include contact with infected blood, instruments or needles - such as IV drug users, health care workers, or public safety workers. Additional potential risk factors include intranasal cocaine use, tattooing and body piercing. Before 1992 the hepatitis C virus was also transmitted through blood transfusions. All blood is now tested for the presence of the virus. The risk post-transfusion has been estimated to be reduced to 0.001% per unit transfused.

Because infection with the virus can be asymptomatic or have vague symptoms, as many as 60% of individuals infected are unaware that they carry the virus. Many are found as a result of routine blood tests. Chronic hepatitis C is a slowly progressive disease that may gradually advance over 10-40 years. When it is acquired in later life there is some evidence that it may progress faster. In those with cirrhosis due to hepatitis C there is an associated increase in the chance of developing hepatocellular carcinoma. Drinking alcohol can make the liver disease worse.

There is no vaccine to prevent hepatitis C. The best prevention is not to use IV drugs, not to share needles, razors, or toothbrushes. Think about the risks if you are thinking about getting a tattoo or body piercing; and get vaccinated against hepatitis B.

According to the Centers for Disease Control and Prevention (CDC), there is an association between sexual exposure to someone with a history of hepatitis, or exposure to multiple sex partners and contraction of hepatitis C. Women with hepatitis C do not need to avoid pregnancy or breast-feeding according to the CDC. Expectant and new parents should be advised that approximately 5 out of every 100 infants born to HCV infected females might be infected. HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding.

Currently there are FDA-approved treatments for hepatitis C. Hepatitis C positive patients should be evaluated by their physicians for liver disease.

References:
1. The American Liver Foundation Fact Sheet on Hepatitis C http://www.liverfoundation.org/
2. Center for Disease Control Fact sheet on Hepatitis C. http://www.cdc.gov/
Find out more about gastrointestinal disorders with The GI System in Detail: http://www.ed4nurses.com/gi-in-detail.htm

By: Patti Radovich, MSN, RN, FCCM
Clinical Nurse Specialist Consultant to Ed4Nurses, Inc.
www.Ed4Nurses.com

Ed4Nurses, Inc.
571 Ledge Road
Macedonia, OH 44056

Pay attention to patient positioning!

Pay attention to patient positioning!

Source: RN

By: Carla Millsaps, RN, BSN

Originally published: January 2, 2006

A patient undergoing abdominal surgery in a Louisiana hospital was placed on the operating table with his arms extended 45 degrees on armboards. The surgeon stood at the patient's right side throughout the hour-and-20-minute procedure. Postoperatively, the patient reported numbness and tingling in his right hand, which persisted well after his discharge from the hospital.

Eventually the patient was diagnosed with an ulnar nerve injury, with numbness and pain that didn't respond to physical therapy. The injury occurred in the OR, the patient alleged in a lawsuit; tests ruled out other causes.

After hearing expert testimony at the trial, the jury found for the plaintiff. The most likely scenario: The patient's arms weren't properly positioned, so the surgeon had to lean on the patient's right arm to perform the operation. The jury assigned fault to the anesthesiologist, the surgeon, and the nurse, as well, for failing to meet the standard of care.1,2

The positioning payoff, short- and long-term
This case, which was decided a decade ago, illustrates the importance of a nurse's role in helping to prepare patients for surgery. Whether you work in a traditional OR, an ambulatory surgery unit, or any other setting where procedures are performed, you'll need to help plan for and maintain proper patient positioning—which can prevent immediate problems as well as long-term pain and disability.3

Proper positioning ensures that the surgical team has ready access to the patient and a clear view of the surgical site. It reduces bleeding, mostly by avoiding venous congestion; minimizes cardiac and respiratory problems; and decreases the risk of pressure-related damage to the skin, nerves, joints, and muscles.4 Proper positioning techniques, used with supportive equipment and devices, contribute to patient safety, according to the Association of Perioperative Registered Nurses.5

Good positioning starts with an assessment
There are many factors to consider in planning how best to safeguard your patients. In addition to finding out what type of procedure is scheduled, how long it will last, and what type of anesthesia will be administered, you will need to determine whether any equipment that could affect positioning will be used—and to identify patients at high risk. Take note of the patient's age, height, and weight. Obese individuals face a greater likelihood of nerve and pressure point injuries, for example, and older people tend to have less flexibility and poorer peripheral circulation than their younger counterparts, making them more susceptible to injury.6

Bear in mind, though, that advanced age alone isn't necessarily an independent risk factor: A healthy 82-year-old may be less vulnerable than an overweight 35-year-old with diabetes.3

Be sure to assess nutritional status and examine the skin of all patients. Lesions, bruises, and dry skin can all contribute to impaired blood flow during surgery.6 Note any preexisting conditions, particularly those affecting the vascular, respiratory, circulatory, neurologic, or immune system. And look for signs of impaired mobility or any physical limitations, such as a bad back, prosthesis, or an implant.

Use your findings to help create a positioning plan well before the procedure, in accordance with your facility's policy and procedure manual, and if applicable, the surgical OR checklist. Share the information with the other clinicians to determine the best way to position the patient before, during, and after the procedure and to shift him from one position to another, as needed.3

There are four basic surgical positions: supine, prone, lateral, and lithotomy. (See the "How to avoid positioning injuries" at the end of the article for illustrations, risks, and safety considerations associated with each.)

Variations include Trendelenburg (patient is supine with head lower than feet), reverse Trendelenburg (patient is supine with head higher than feet), modified Fowler's (variation of reverse Trendelenburg; patient is sitting), and Kraske (variation of prone position; patient lies on his stomach in a jackknife, achieved by flexing the table at center break).7

The choice of position will depend on the type of procedure. But any of them can affect the major body systems, and, coupled with the effects of anesthesia, become a potential danger for patients in the following ways:

Respiratory

Some positions—including supine—can restrict movement of the rib cage or diaphragm and impede airflow, particularly with obese patients. Obese patients must be seated upright for the duration of most procedures because of increased abdominal pressure on the chest when they are supine.3,6

Circulatory

Lithotomy positions and the severe head-down positions used during some laparoscopic procedures may compromise blood flow to the lower extremities or venous blood return to the heart.3 Pressure or obstruction of a vessel can cause the greatest amount of damage to the cardiovascular system.7 This can be avoided by reducing the procedure time, if possible, or by moving limbs and massaging them at regular intervals during the procedure.

Skin

Friction and pressure on soft tissues, especially over bony prominences, may result in changes ranging from mild irritation to severe pressure-induced ischemia.3

Neurologic

Pressure or obstruction caused by faulty positioning is a common cause of nerve injury, as the case of the patient with ulnar nerve damage makes clear. Motor or sensory nerve damage can happen within minutes, and can have a long-term effect.7

Some positioning problems are particularly likely in specific patient groups: Men 40 – 70 years old who undergo abdominal or pelvic procedures have a higher risk of developing ulnar neuropathy, for example.3 Women over 60 have a greater risk of developing obturator and lateral femoral cutaneous neuropathies after procedures in which they remain in the lithotomy position, such as cystoscopies and other gynecologic outpatient procedures.3 Being aware of patients' particular risks will help you determine when—and where—to provide extra protection.

Complete article

Patient Safety: Medication Use and the Ageing Population

Patient Safety: Medication Use and the Ageing Population
World Health Professions Alliance Fact Sheet

Background: Medication Use in the Ageing Population

Worldwide, the proportion of people age 60 and over is growing faster than any other age group. Between 1970 and 2025, a growth in older populations of some 870 million or 380% is expected. This would lead to a total population of about 1.2 billion people over the age of 60 in the year 2025.

As the population ages, the demand rises for medications that are used to delay and treat chronic diseases, alleviate pain and improve quality of life. This increased use of a number of medications raises the risk that medicine-related problems will occur. A 1991 study concluded that adverse medicine-related illnesses in the elderly are significant causes of personal suffering and costly preventable hospital admissions.

In many parts of the world up to 80% of illness episodes are self-treated with modern pharmaceuticals. In developing countries it is confirmed that pharmaceuticals account for 60 to 90 % of out-of-pocket household spending on health, while pharmaceutical expenditure ranges between 25% and 65% of total public and private health expenditure. With the proper use of these medicines individuals can experience increased longevity and quality of life and in many cases illnesses can be treated or delayed without the need of more invasive procedures such as surgery. However due to the high consumption of medicines and self-treatment by all, especially the ageing population, the topic of proper medication use and safety is being brought to the forefront of public health discussions.

Patient Safety and Medication Use
In general, medicines are registered by government bodies to certify that they contain the active ingredients to ensure safety and hold a minimum standard of good quality. Serious concern about patient safety exists when the source and content of medicines are unknown and when medicines are distributed and sold without proper regulation (ie. medications sold in outdoor markets). The public health risk associated to the use of medicines of poor quality, or which contain little or none of the active ingredient/medicine or other ingredients, is high.

Apart from the safety of the medicinal product itself, adverse events or 'medication errors' that may lead to inappropriate medication use or patient harm can be related to many causes such as professional practice, procedures, and systems including prescribing; order communication; product labelling; packaging; compounding; dispensing; distribution; administration; education; monitoring; and use. Patient Safety is at risk when patients do not take medicines appropriately. Unclear instructions and unclear labelling of the medication, non-adherence when using medications for chronic conditions, as well as, taking non-prescription medicines or herbal products without the advice of a health professional may lead to serious adverse events. It is estimated that in the range of 50% of patients in developed countries, and less in developing countries continue to take chronic medications on a long-term basis. Patients taking various medications simultaneously can benefit from medication reviews held by health professionals to ensure that the prescribed and non-prescribed medicines offer the most optimal therapy for the individual.

Health Professionals and Medicines
Pharmacists, physicians and nurses are involved in patient medication use through dispensing, prescribing and administering medications. As health professionals they provide appropriate care and medicines, and act as sources of information and advice to patients.

To avoid complications, medicine use, contraindications, and potential adverse effects need to be discussed between patients and health professionals. This allows both the patient and health professionals to monitor the medical condition and to take appropriate actions if a medication error occurs. An open dialogue and regular communication between patients and health professionals is a positive means towards improving patient safety in medication use.

1 Need study details for Gurwitz and Avorn
- The International Council of Nurses (ICN) is a federation of more than 120 national nurses' associations representing the millions of nurses world-wide. Operated by nurses for nurses since 1899, ICN is the international voice of nursing and works to ensure quality care for all and sound health policies globally.
- The International Pharmaceutical Federation (FIP) is the world-wide federation of pharmacists and pharmaceutical scientists, with the mission of representing and serving pharmacy and pharmaceutical sciences around the globe. Founded in 1912, FIP promotes appropriate use of, and access to, medicines for all through achieving the highest standards in pharmaceutical science, professional practice, public health and patient care.
- The World Medical Association (WMA) is a global federation of national medical associations, representing the millions of physicians world-wide. Acting on behalf of physicians and patients, the WMA endeavours to achieve the highest possible standards of medical science, education, ethics and health care for all people.

For further information contact Linda Carrier-Walker
Tel : (+41 22) 908 0100 -
Fax : (+41 22) 908 0101
email: carrwalk@icn.ch
Web site www.whpa.org

Related Documents
FIP Guidelines for the Labels of Prescribed Medicines, FIP 2001, http://www.fip.org
ICN on Healthy Ageing: A Public Health and Nursing Challenge, ICN Fact Sheet, http://www.icn.ch
Nursing Care of the Older Person, ICN Position Statement, ICN 1998, http://www.icn.ch
World Medical Association Declaration on the Abuse of the Elderly, WMA September 1989, http://www.wma.net
_______________________
References
Adherence to Long-term Therapies: Policy for Action, World Health Organisation 2001, WHO/MNC/CCH/01.02
FIP Statement of Professional Standards: Medication Errors Associated with Prescribed Medication, FIP 1999, http://www.fip.org
FIP Statement of Policy on Counterfeit Medicines, FIP 1999, http://www.fip.org
Health and Ageing: A Discussion Paper, World Health Organisation 2001, WHO/NMH/HPS/01.1
Public Education in Rational Drug Use: a Global Survey, World Health Organisation 1997, WHO/DAP/97.5, http://www.who.int/medicines
WHO medicines strategy: Expanding access to essential drugs, Report by the Secretariat, 109th World Health Organisation Executive Board Meeting 2002, EB109/7

ICN/FS/02 #02May 2002

Patient Safety

Patient Safety
World Health Professions Alliance Fact Sheet

Press Release 29 April 2002 -
Health Professionals Call for Priority on Patient Safety

Background
Health care interventions are intended to benefit the public, but due to the complex combination of processes, technologies and human interactions there is an inevitable risk that adverse events will happen. Much evidence has been built on risks in hospitals, however information about adverse events occurring in healthcare settings such as physicians’ offices, nursing homes, pharmacies and patients’ homes are not very well documented. Identifying and reducing the occurrence of these errors and improving the safety and quality of health care has therefore been brought forward as a priority issue for health services around the world.

An adverse event can be defined as harm or injury caused by the management of a patient’s disease or condition by health care professionals rather than by the underlying disease or condition itself. Although human errors may sometimes precipitate serious failures, there are usually deeper, systemic factors, which if addressed earlier would have prevented the errors. Hence, the enhancement of patient safety involves a wide range of actions in the recruitment, training and retention of health care professionals, performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care.

There is a growing evidence that inadequate institutional staffing levels are correlated with increase in adverse events such as patient falls, bed sores, medication errors, nosocomial infections and readmission rates that can lead to longer hospital stays and increased hospital mortality rates. In short, inadequate human resources present a serious threat to the safety and quality of health care.

Some facts and figures about patient safety
- The 1995 Quality in Australian Health Care Study (QAHCS) found an adverse-event rate of 16.6% among hospital patients.
- The Hospitals for Europe’s Working Party on Quality Care in Hospitals estimated in 2000 that every tenth patient in hospitals in Europe suffers from preventable harm and adverse effects related to his or her care.
- 75% of the adverse drug events in a Utah-Colorado Study in the United States were attributable to system failures. Most adverse events were not the result of negligence or lack of training, but rather occurred because of latent causes within systems.
- In NHS Hospitals adverse events in which harm is caused to patients occur at a rate in excess of 850,000 a year.
- According to a survey conducted by the Robert Wood Johnson Foundation, 95% of doctors and 89% of nurses in the United States have witnessed a serious medical error.
- Poor quality healthcare is responsible for more than 30% of avoidable deaths in Italy.

The situation in developing countries
In developing countries the probability of adverse events is much higher than in industrialized nations due in part to the poor state of infrastructure and equipment, unreliable supply and quality of medicines, shortcomings in waste management and infection control, low number and poor performance of personnel because of low motivation or insufficient technical skills, and severe under financing of essential operating costs of health services.
- At least 50% of all medical equipment in most developing countries is unusable, or only partly usable, at any given time.
- In the Newly Independent States, about 40% of hospital beds are located in structures originally built for other purposes. As a result the correct infrastructure for radiation protection and infection control is very difficult to install.
- Approximately 77% of all reported cases of substandard and counterfeit drugs occur in developing countries.

Financial impact
Adverse health care events carry a high financial cost. About half of the expenditures for preventable errors are for direct health care costs.

The total national cost of preventable adverse health care events in the United States, including lost income, disability and medical expenses, is estimated at between US$17 000 million and US$ 29 000 million annually.

In the UK the NHS estimates that adverse events cost £2 billion a year in additional hospital stays alone.

Recommendations for action
1. Patients and the community
- Inform healthcare professionals of all your medicines taken and medical conditions.
- Ask questions to clarify information and increase understanding about health conditions, medicines and healthcare provision.
- Make sure to get the results of any test or procedure.
- Report errors or adverse events to the proper authorities.
2.Health Professionals
- Take an active role in assessing the safety and quality of care in practice.
- Improve communication with patients and other healthcare professionals.
- Inform patients of potential risks.
- Work to improve practice-related systems.
- Report adverse events to the appropriate authorities.
- Strengthen collaboration aspects of drug treatment plans.
3.Hospitals, clinics, general practice, drug distribution and other facilities
- Maintaining adequate human resource levels.
- Focus on improving the systems of delivering care, not blaming individuals.
- Establish rigorous infection control programmes.
- Standardise treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.
- Avoid similar-sounding and look-alike names and packages of medication.
4.Governments
- Establish national reporting systems to record, analyse and learn from adverse incidents.
- Promote a culture of reporting.
- Emphasise safety as a prime concern in health system performance and quality management.
- Implement mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice and progress is tracked.
- Develop evidence-based policies that will improve health care.
- Develop mechanisms, for example through accreditation and other means, to recognize the characteristics of health care providers that offer a benchmark for excellence in patient safety.

The International Council of Nurses (ICN) is a federation of more than 120 national nurses' associations representing the millions of nurses world-wide. Operated by nurses for nurses since 1899, ICN is the international voice of nursing and works to ensure quality care for all and sound health policies globally.

The International Pharmaceutical Federation (FIP) is the world-wide federation of pharmacists and pharmaceutical scientists, with the mission of representing and serving pharmacy and pharmaceutical sciences around the globe. Founded in 1912, FIP promotes appropriate use of, and access to, medicines for all through achieving the highest standards in pharmaceutical science, professional practice, public health and patient care.

The World Medical Association (WMA) is a global federation of national medical associations, representing the millions of physicians world-wide. Acting on behalf of physicians and patients, the WMA endeavours to achieve the highest possible standards of medical science, education, ethics and health care for all people.

For further information contact
Linda Carrier-Walker Tel : (+41 22) 908 0100 - Fax : (+41 22) 908 0101
email:carrwalk@icn.ch
Web site www.whpa.org

References
Quality of care: patient safety ,World Health Organization Executive Board EB109/9, 5 December 2001 http://www.who.int/gb/EB_WHA/PDF/EB109/eeb1099.pdf (accessed 22 April 2002)
Italy: Better Healthcare could cut deaths, Reuters Healthcare, January 18, 2002 citing study of The 2001 Prometeo Atlas of Italian Healthcare.
Health Care Professionals: backbone of quality and safety of care, Statement of the WHPA At the WHO Executive Board, 16 January 2001
An Organisation with a Memory, Report of the UK Department of Health, 2000 http://www.doh.gov.uk/orgmemreport/index.htm (accessed 22 April 2002)
Building a Safer NHS for Patients, Report of the UK Department of Health, April 2001 http://www.doh.gov.uk/buildsafenhs (accessed 22 April 2002)
Pursuing Perfection, Research conducted for the Robert Wood Johnson Foundation, March/April 2001. http://www.rwjf.org/news/releaseDetail.jsp?id=1017609851350&contentGroup=rwjfreleases (accessed 22 April 2002)
To Err is Human: Building a Safer Health System, Institute of Medicine. November 1999.
29 April 2002

ICN on Preventing Needlestick Injuries

ICN on Preventing Needlestick Injuries

Facts and Issues

At least one in eight health care workers receives a needlestick injury potentially exposing them to serious or fatal infections.

Accidental needlestick injuries are the predominant sharps-related problem in industrialized countries. American health workers suffer 800,000 to 1 million needlesticks annually, not including the vast number that go unreported. There are more than 100,000 needlestick injuries in UK hospitals each year. Needlesticks are virtually undocumented in developing countries, but probably equal or exceed those in the industrial world. More than 20 blood borne diseases can be transmitted as a result of exposure to blood. Inadequate waste disposal systems extend the problem beyond health workers to cleaners, laundry workers, porters, 'rag pickers' and the general community2.

This is a true scenario.
How can it be prevented?

An AIDS patient became agitated and tried to remove the intravenous catheters. Hospital staff struggled to restrain the patient. During the struggle, an IV infusion line was pulled, exposing the connector needle. A nurse recovered the connector needle at the end of the IV line and attempted to reinsert it. The patient kicked her arm, pushing the needle into the hand of the second nurse. Three months later, the nurse who sustained the needlestick injury tested positive for HIV1.

In some countries, health care providers feel obliged to give injections to satisfy their clients` perceptions of proper treatment. Three studies in Sub-Saharan Africa and Asia found that between 60 and 80% of all injections given were unnecessary and sometimes dangerous. The most frequently injected medications were antibiotics2.

Impact on nurses

Nurses have the highest rate of needlestick injury among health care workers. A health worker's risk of infection from a needlestick injury depends on the pathogen involved, the immune status of the worker, and the severity of the needlestick. The probability that a single needlestick will result in disease is 3 to 5 chances in 1 000 for HIV, 300 chances in 1 000 for Hepatitis B, and 20 to 50 chances in 1 000 for Hepatitis C.

Accidental needlesticks account for 86% of all occupationally related infectious disease transmission. The emotional impact of a needlestick injury can be severe, even when a serious infection is not transmitted, particularly when the injury involves exposure to HIV. In one study of 20 health care workers with an HIV exposure, 11 reported acute severe distress, 7 had persistent moderate distress, and 6 quit their jobs as a result of their exposure3.

The economics of needlestick injuries

According to the American Hospital Association, one case of serious infection by bloodborne pathogens can result in $1 million of employer costs related to testing, follow-up, lost time and disability payments. The cost of follow-up for a high-risk exposure is almost $3 000 per needle stick injury even when no infection occurs. Safe needle devices cost only 28¢ more than standard devices. Hospitals in California are expected to save over $100 million per year after implementing legislation requiring safe needle devices4.

Nurses` Rights

According to the International Labour Organization (ILO) all appropriate measures should be taken to prevent, reduce or eliminate risks to the health of nursing personnel.

This includes5:
- A comprehensive national policy on occupational health.
- The establishment of occupational health services.
- Access to health surveillance, preferably during working hours and at no cost to the worker concerned.
- Medical confidentiality of health surveillance.
- Financial compensation for those exposed to special risks.
- Participation in all aspects of protection provisions.

What you can do to protect yourself and others:
- Avoid the use of needles where safe and effective alternatives are available.
- Avoid recapping needles.
- Participate in blood borne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.
- Report all needlestick and other sharps related injuries to ensure that you receive appropriate follow-up care.
- Advocate for monitoring and safe work practices, including data collection.
- Educate and lobby for the development of safer technology.
- Advocate for screening, post exposure counseling, prophylaxis, legal aid, and support groups.
- Use purchasing power to buy safe equipment.
- Create/maintain a safe, comprehensive disposal system.
- Promote safety awareness.
- Evaluate prevention efforts and provide feedback on performance.

For further information please contact

ICN at icn@icn.ch

July 2000 ____________________
1 National Institute for Occupational Health and Safety (NIOSH). Preventing Needlestick Injuries in Health Care Settings. November, 1999. Publication NR. 2000-108.
2 WHO Safe Injection Global Network
3 Henry et al., 1990. NIOSH Preventing Needle Stick Injuries in Health Care Settings
4 American Nurses Association, Nursing Facts: Needlestick Injury, 1998
5 ILO Recommendation 157: Employment and conditions of work and life of nursing personnel