trying to push a used needle into a movable sheath and then turning the syringe upwards to let the sheath cover the needle could lead to "chasing" the sheath across the surface of the table, flipping the sheath off on to the floor, and injuring a bystander in the process. The Saf-T-Cap and other similar devices would still require a steady hand and eye to put the needle into the sheath at the first attempt. There might also be the temptation to steady the device with the other hand while using it, thereby increasing the risk of a needlestick injury to that hand. We accept that if there are situations where recapping is unavoidable, the Saf-T-Cap is simple enough and better in many aspects than some of the more complicated alternative multiple hole devicessome with cutter attachments to remove the needle from the syringe. The advice of the Centers for Disease Control and the British Medical Association,2 that resheathing is generally inadvisable, is still sound. We would also support the requirement for all sharps containers to meet British Safety standards (7320). Rather than recommending resheathing we recommend the adequate provision, use, and disposal of robust sharps containers at suitable intervals and a programme to educate all staff in the safe disposal of sharps, as required by the Control of Substances Hazardous to Health Regulations 1988. T C AW
Institute of Occupational Health, University of Birmingham, Birmingham A E COCKCROFT
Occupational Health Unit, Hampstead Health Authority, London P J BAXTER Department of Community Medicine, University of Cambridge, Cambridge
J R CARRUTHERS Occupational Health Service,
King's College Hospital, London N A MITCHELL-HEGGS
Department of Occupational Health, St George's Hospital, London H A WALDRON
Department of Occupational Health, St Mary's Hospital, London
1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code ofpractice for the safe use and disposal ofsharps. London: BMA, 1990.
It is, however, the responsibility of the infection control team to keep on at our clinical colleagues to rouse themselves from the habits of a lifetime and at managers to make these resources readily available so all may comply with our guidelines. It is only then that we will be taken seriously and not chastised for handing out counsels of perfection from ivory towers. Finally, we believe that those involved in infection control have a great deal to offer in upholding and re-emphasising the need for safe and efficient practices in our hospitals and in the community, especially in the face of continued pressures to cut corners, skimp, and save. We must, however, be seen to be effective and authoritative in these areas if our clinical colleagues are to be convinced that some of their hard won clinical budgets should be spent in maintaining our services in the future. SARAH MAXWELL MARGARET VEGUILLAS Pathology Department, Stepping Hill Hospital, Stockport SK2 7JE 1 Anderson DC, Blower AL, Packer LA, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 Valentine C, Bright P. Preventing needlestick injuries. BMJ 1991;302:1079. (4 May.)
Living without tears SIR,-I was interested to read the article "Living without tears" by Ms Joanna Johnson. There now exists a mutual self help organisation called the British Sjogren's Syndrome Association (BSSA, 7 Winchdells, Bennetts End, Hemel Hempstead, Hertfordshire HP3 8HZ), which welcomes also those with non-Sjogren dry eye or dry mouth problems to become members and join its activities. The association aims to support sufferers from Sjogren's syndrome and related disorders and also patients with other dry eye problems; increase awareness of these disorders in the medical and dental professions and among the general public; and promote and support research in these complex ailments. Several branches of the association have recently been formed, mainly in the bigger centres such as Manchester and Glasgow. The first national conference of the British Sjogren's Syndrome Association will be held on 19 July 1991 at the University of Birmingham Conference Centre. B PAL
University Hospital of South Manchester,
SIR,-We would like to add a few observations to the debate over whether or not to sheath.' 2 Over the past six months there have been 69 incidents in our district in which the transmission of bloodborne viruses has been a possibility42 involved actual handling during a procedure; 13, improper disposal; two, patients' own sharps; 11, a scratch or bite; and one a splash in the eye. These show that, although efforts to ensure the safe disposal of sharps must still be maintained, greater attention should probably be given to the major risk area of the actual procedural handling of sharps and needles. As large volumes of blood are potentially available at this point these incidents pose by far the greatest danger to health care workers, as indeed indicated by Dr D C Anderson and colleagues. ' We agree that "faced with a sharps box [conforming to BS 7320], a needle and sheath"2 the sensible, safe, and correct action is to dispose of the unsheathed needle straight into the box. In the real world, however, such an ideal situation rarely exists. We are currently trying to make available small, user friendly sharps boxes at every point of use. Yet we foresee that equipment availability, financial constraints, management inactivity, and user apathy are all too likely to conspire against this eminently achievable state of bliss.
BMJ VOLUME 302
1 JUNE 1991
Manchester M20 8LR 1 Johnson J. Living without tears. BMJ 1991;302:1158-9.
(11 May.)
Identification of patients when taking blood SIR,-The BMJ has published an excellent series of articles in the "ABC of Transfusion," which later has appeared as a book edited by Dr Marcela Contreras.' In the chapter on testing before transfusion, and blood ordering policies, however, the authors state, "The person taking the blood sample must ensure that the patient is properly identified, either by speaking to the patient or-if the patient is unconscious-by examining the wrist band. Ideally, the tubes should be labelled after they have been filled with blood." The procedure described in the last sentence seems very dangerous to us. The following example illustrates why. A cord blood sample was drawn from a newborn in the delivery room, but unfortunately the tube was left unlabelled-and forgotten and not sent to the blood bank. The delivery room was cleared and cleaned for the next patient, but the unlabelled sample was not removed. During the subsequent
delivery someone labelled the tube with identification characteristics for that delivery. The results of blood grouping on this sample did not fit mendelian rules of inheritance of the ABO groups between the recorded mother and child. The error was finally resolved, indicating to us once more that proper labelling of test tubes before drawing any blood is an important step in the sequence to ensure that blood in the tube matches patient identification on the label. One might think that the person who takes the blood sample should take the time to label the tubes properly after drawing the blood and before engaging in other work. In the stressed work situations in today's hospital setting this will often be impossible. Doctors and nurses often must leave their work in a hurry to deal with acute situations. In Denmark the only approved sequence of steps when taking blood for grouping or compatibility testing was described by E Freiesleben.2 The following steps are mandatory: the requisition is filled in and the test tubes labelled with the patient's full name and civil register number (this social security number unequivocally identifies the person and is a blessing for safe blood banking and computerisation). Then the venepuncture is done, and while the blood is streaming into the tube the patient is asked to state his or her name and his number (or date of birth, which comprises the first six figures in the number), and the person drawing blood checks that this information accords with the label on the tube. For unconscious patients and children, an assistant reads the full name and number from the patient's wrist band, and the labelling of the tube is controlled by the person drawing blood. If health care workers drawing blood samples always adhere to these rules the mistakes due to mixed up specimens can be greatly diminished. J0RGEN GEORGSEN UFFE BRODTHAGEN NIELS GRUNNET SVEND ERIK HOVE JACOBSEN CASPER JERSILD Regional Centre for Blood Transfusion and Clinical Immunology, Aalborg Hospital, DK-9100 Aalborg, Denmark 1 Contreras M, Mollison PL. Testing before transfusion, and blood ordering policies. In: Contreras M, ed. ABC of transfusion. London: BMJ, 1990:6. 2 Freiesleben E. Vejiledning i blodtransfusion [Recommendations for blood transfusion]. Vol 1. Copenhagen: Blood Transfusion Board, 1965:18-9.
AUTHOR'S REPLY, - Haemolytic transfusion reactions and deaths resulting from transfusions are still due mainly to identification mistakes. One of the most important causes of such mistakes is the failure to label sample tubes correctly. The main problem is one of non-compliance with standard operating procedures or hospital guidelines. ' Dr Georgsen and colleagues have given us an example of failure of compliance when a tube was not labelled after the blood had been drawn. The health care worker concerned was negligent by leaving a sample unlabelled in theatre. Fortunately, apart from a great deal of aggravation, the infants concerned seemed to have come to no harm. On the other hand, I have also had to deal with investigations of transfusion fatalities because phlebotomists labelled tubes for two or three patients before drawing the blood. The consequence was that samples went into the tubes labelled for the wrong patient, with fatal consequences (group 0 recipient labelled as A and given group A blood). Professor Mollison and I were prompted to advise on labelling the tubes after they have been filled with blood because of our personal experiences.
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Institute of Occupational Health, University of Birmingham, Birmingham A E COCKCROFT
Occupational Health Unit, Hampstead Health Authority, London P J BAXTER Department of Community Medicine, University of Cambridge, Cambridge
J R CARRUTHERS Occupational Health Service,
King's College Hospital, London N A MITCHELL-HEGGS
Department of Occupational Health, St George's Hospital, London H A WALDRON
Department of Occupational Health, St Mary's Hospital, London
1 Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 British Medical Association. A code ofpractice for the safe use and disposal ofsharps. London: BMA, 1990.
It is, however, the responsibility of the infection control team to keep on at our clinical colleagues to rouse themselves from the habits of a lifetime and at managers to make these resources readily available so all may comply with our guidelines. It is only then that we will be taken seriously and not chastised for handing out counsels of perfection from ivory towers. Finally, we believe that those involved in infection control have a great deal to offer in upholding and re-emphasising the need for safe and efficient practices in our hospitals and in the community, especially in the face of continued pressures to cut corners, skimp, and save. We must, however, be seen to be effective and authoritative in these areas if our clinical colleagues are to be convinced that some of their hard won clinical budgets should be spent in maintaining our services in the future. SARAH MAXWELL MARGARET VEGUILLAS Pathology Department, Stepping Hill Hospital, Stockport SK2 7JE 1 Anderson DC, Blower AL, Packer LA, Ganguli LA. Preventing needlestick injuries. BMJ 1991;302:769-70. (30 March.) 2 Valentine C, Bright P. Preventing needlestick injuries. BMJ 1991;302:1079. (4 May.)
Living without tears SIR,-I was interested to read the article "Living without tears" by Ms Joanna Johnson. There now exists a mutual self help organisation called the British Sjogren's Syndrome Association (BSSA, 7 Winchdells, Bennetts End, Hemel Hempstead, Hertfordshire HP3 8HZ), which welcomes also those with non-Sjogren dry eye or dry mouth problems to become members and join its activities. The association aims to support sufferers from Sjogren's syndrome and related disorders and also patients with other dry eye problems; increase awareness of these disorders in the medical and dental professions and among the general public; and promote and support research in these complex ailments. Several branches of the association have recently been formed, mainly in the bigger centres such as Manchester and Glasgow. The first national conference of the British Sjogren's Syndrome Association will be held on 19 July 1991 at the University of Birmingham Conference Centre. B PAL
University Hospital of South Manchester,
SIR,-We would like to add a few observations to the debate over whether or not to sheath.' 2 Over the past six months there have been 69 incidents in our district in which the transmission of bloodborne viruses has been a possibility42 involved actual handling during a procedure; 13, improper disposal; two, patients' own sharps; 11, a scratch or bite; and one a splash in the eye. These show that, although efforts to ensure the safe disposal of sharps must still be maintained, greater attention should probably be given to the major risk area of the actual procedural handling of sharps and needles. As large volumes of blood are potentially available at this point these incidents pose by far the greatest danger to health care workers, as indeed indicated by Dr D C Anderson and colleagues. ' We agree that "faced with a sharps box [conforming to BS 7320], a needle and sheath"2 the sensible, safe, and correct action is to dispose of the unsheathed needle straight into the box. In the real world, however, such an ideal situation rarely exists. We are currently trying to make available small, user friendly sharps boxes at every point of use. Yet we foresee that equipment availability, financial constraints, management inactivity, and user apathy are all too likely to conspire against this eminently achievable state of bliss.
BMJ VOLUME 302
1 JUNE 1991
Manchester M20 8LR 1 Johnson J. Living without tears. BMJ 1991;302:1158-9.
(11 May.)
Identification of patients when taking blood SIR,-The BMJ has published an excellent series of articles in the "ABC of Transfusion," which later has appeared as a book edited by Dr Marcela Contreras.' In the chapter on testing before transfusion, and blood ordering policies, however, the authors state, "The person taking the blood sample must ensure that the patient is properly identified, either by speaking to the patient or-if the patient is unconscious-by examining the wrist band. Ideally, the tubes should be labelled after they have been filled with blood." The procedure described in the last sentence seems very dangerous to us. The following example illustrates why. A cord blood sample was drawn from a newborn in the delivery room, but unfortunately the tube was left unlabelled-and forgotten and not sent to the blood bank. The delivery room was cleared and cleaned for the next patient, but the unlabelled sample was not removed. During the subsequent
delivery someone labelled the tube with identification characteristics for that delivery. The results of blood grouping on this sample did not fit mendelian rules of inheritance of the ABO groups between the recorded mother and child. The error was finally resolved, indicating to us once more that proper labelling of test tubes before drawing any blood is an important step in the sequence to ensure that blood in the tube matches patient identification on the label. One might think that the person who takes the blood sample should take the time to label the tubes properly after drawing the blood and before engaging in other work. In the stressed work situations in today's hospital setting this will often be impossible. Doctors and nurses often must leave their work in a hurry to deal with acute situations. In Denmark the only approved sequence of steps when taking blood for grouping or compatibility testing was described by E Freiesleben.2 The following steps are mandatory: the requisition is filled in and the test tubes labelled with the patient's full name and civil register number (this social security number unequivocally identifies the person and is a blessing for safe blood banking and computerisation). Then the venepuncture is done, and while the blood is streaming into the tube the patient is asked to state his or her name and his number (or date of birth, which comprises the first six figures in the number), and the person drawing blood checks that this information accords with the label on the tube. For unconscious patients and children, an assistant reads the full name and number from the patient's wrist band, and the labelling of the tube is controlled by the person drawing blood. If health care workers drawing blood samples always adhere to these rules the mistakes due to mixed up specimens can be greatly diminished. J0RGEN GEORGSEN UFFE BRODTHAGEN NIELS GRUNNET SVEND ERIK HOVE JACOBSEN CASPER JERSILD Regional Centre for Blood Transfusion and Clinical Immunology, Aalborg Hospital, DK-9100 Aalborg, Denmark 1 Contreras M, Mollison PL. Testing before transfusion, and blood ordering policies. In: Contreras M, ed. ABC of transfusion. London: BMJ, 1990:6. 2 Freiesleben E. Vejiledning i blodtransfusion [Recommendations for blood transfusion]. Vol 1. Copenhagen: Blood Transfusion Board, 1965:18-9.
AUTHOR'S REPLY, - Haemolytic transfusion reactions and deaths resulting from transfusions are still due mainly to identification mistakes. One of the most important causes of such mistakes is the failure to label sample tubes correctly. The main problem is one of non-compliance with standard operating procedures or hospital guidelines. ' Dr Georgsen and colleagues have given us an example of failure of compliance when a tube was not labelled after the blood had been drawn. The health care worker concerned was negligent by leaving a sample unlabelled in theatre. Fortunately, apart from a great deal of aggravation, the infants concerned seemed to have come to no harm. On the other hand, I have also had to deal with investigations of transfusion fatalities because phlebotomists labelled tubes for two or three patients before drawing the blood. The consequence was that samples went into the tubes labelled for the wrong patient, with fatal consequences (group 0 recipient labelled as A and given group A blood). Professor Mollison and I were prompted to advise on labelling the tubes after they have been filled with blood because of our personal experiences.
1337
