Stray Needles and Swiss Cheese Safety

This post is about the difference between following safety guidelines and creating safety.

Of the 160 incidents reported so far in our AERD, 26% are related in some way to forgotten or stray needles. I’m confident that we can assume that forgotten and stray needles are under-reported. After my very first acupuncture treatment ever, in 1991, at a high-end private practice in Northwest Portland, I discovered a needle left in GV 20 while I was waiting at the bus stop. (A sign that acupuncture safety was my destiny!) The last time I swept the clinic floor after a shift I’d supervised, I found oh, five or six needles on the treatment room floor and one in the lobby.

Here’s what the Clean Needle Technique Manual has to say about forgotten needles:

"Since 1999, prospective studies identify a small but persistent number of patients in which needles are not removed from the patient before they leave the treatment room or clinic...Some very basic steps can dramatically decrease the occurrence of this practitioner mistake...Documenting the number of needles inserted at the time of insertion and then counting and documenting the number of needles removed at the end of a treatment will help prevent this AE. Use counting and proper documentation to check for missing needles. However, if needle counts do not match, palpation may be necessary but should be done with extreme caution." (pg 9)

Counting needles in and out is certainly a successful strategy for some acupuncturists. Please forgive me for suggesting, though, that the CNT manual makes it sound like preventing forgotten and stray needles is easier than it actually is in real life -- and that can lead to problems.

First, the practice of counting needles out can run into competing safety issues. Most obvious is an incidence of needle shock, when the acupuncturist needs to pull needles as fast as possible before the patient potentially hits the floor. As Jersey points out, though, needle shock/fainting is just one example of things that can happen during treatment that aren’t under anyone’s control. Some of those things will also require that the acupuncturist pull needles as fast as possible without counting. In my experience, more common than needle shock are trauma triggers leading to panic attacks or similar instances in which the patient can’t control their anxiety, at which point the needles need to come out before the patient literally flees the room. And even more common than panic attacks are incidences when patients suddenly realize they need to use the bathroom immediately and make a run for it with all their needles still in.

Second, believing that it should always be easy to count needles in and out runs into issues of inclusion. It’s much easier to count needles in and out in certain settings, with certain patients. We’ll get into “inappropriate patient behavior” as a topic in its own right later, but it’s worth noting here that if you try to control your patients’ behavior to the degree of making sure they never, ever take their own needles out (intentionally) or (unintentionally) send their needles flying in every direction, you’re going to have a hard time treating some people who would otherwise benefit enormously from acupuncture.

There are a lot of reasons someone might not be able to stop moving their limbs and sit still completely. There are a lot of reasons it might not occur to somebody in the moment that they shouldn’t pull their own needles, even if you told them they shouldn’t. And as a result you will occasionally end up with needles on the floor, in the trash can, in patients’ clothes and otherwise outside of the short list of places where you want needles to be: in the packet, in your hands, in the patient’s body, in the biohazard container.

Just as valid are the constraints of certain settings. In the trauma-informed drug treatment program where patients are coming and going quickly, with babies and children and emotional support dogs in tow, trying to fit their acupuncture in between endless other appointments -- if you’re slowly and meticulously counting a stressed-out mom’s ear needles while she needs to hurry to get somewhere else, you might be discouraging her from continuing to make time for acupuncture (pro tip: it’s already a herculean feat on her part). In the low-cost, fee-for-service community clinic where you need to move as fast as you can in order to treat a lot of people so that you can pay the bills, counting needles in and out and documenting the count in the patient’s chart might be beyond what you can manage.

Time is a resource; some patients and practitioners have more than others.

But there’s also more than one way to do safety. More safety is better than perfect safety, and you always need more than one layer of Swiss cheese. If you can count needles in and out, congratulations! But you should also plan to: orient patients in the initial intake to expect to help you locate and take out all their needles; be ready to pull needles really fast sometimes; have an effective needle magnet; and save enough energy for the end of your shift to do a good job with sweeping. Above all, you should plan on patients not behaving perfectly, with regard to needles or anything else.