Mary Jo Bellush


Establishing a sustainable, proactive approach to reduce sharps injuries

Mary Jo Bellush, MSN, RN, CIC
Excela Health
Greensburg, Pa

Mary Jo Bellush developed a comprehensive, proactive campaign that significantly reduced the number of sharps injuries across her hospital system.

In 2013, LEAN methodology revealed that blood and body fluid (BBF) injuries were the number one OSHA preventable injury at Excela Health. Research showed that the hospital system had an entirely reactive approach to these injuries. “There were no preventions in place, no standardization for safety-device use, and employees were unsure about how to report an injury,” Bellush said. Leveraging LEAN methodology again, she set out to identify root causes of the hospital’s injuries.

Mandatory roundtable reviews of every injury revealed that 95 percent were caused by employees rushing through tasks and not always following proper procedures. Misuse of safety devices was another issue. As one example, the infection prevention and control (IPC) team discovered that surgeons were breaking the safety covers off needles during surgery because they obstructed their view of the surgical site. “Once we identified these injuries as preventable, we were able to make them a strategic priority for the organization,” Bellush said.

The IPC team created a proactive campaign that emphasized safety awareness, continuous improvement, and prevention. Safety is now a topic in daily LEAN meetings. At quarterly breakfasts, senior leadership and “safety advocates” review injury statistics and causes, and identify steps to prevent them. A “Safer Medical Device” task force also meets quarterly. 

To standardize safety procedures and educate frontline staff, the IPC team made step-by-step instructional documents available online, and created a website page that allows employees to submit safety concerns and device suggestions. Surgeons participated in mandated training to understand their safety-device options. When an injury does occur, the IPC team distributes a safety memo to ensure staff learn from it. 

Between 2014 and 2016, BBF injuries decreased by nearly 50 percent, even as the hospital’s staff grew. “Collaboration and standardization at all levels really helped us be successful,” Bellush said.