Cutting Injuries in an Academic Pathology Department

Bobbi S. Pritt, MD; Brenda L. Waters, MD

● Context.—Cutting injuries pose an infrequent but serious threat to anatomic pathology personnel. Although cut-resistant gloves may reduce this danger, it is imperative to recognize specific behaviors that increase the chance of an injury. Objective.—To examine the incidence of cutting injuries in an academic pathology department and the mechanisms by which such injuries occurred. Design.—Hospital Report of Event forms completed for laboratory incidents of cutting injury from March 1998 to September 2003 were evaluated. Further information regarding the incidents was obtained, when possible, by interviews with those personnel involved. Setting.—A university-based pathology laboratory was the setting for this study. On average, 505 autopsies and 29 000 surgical specimens were processed each year during the 5.5-year time period. he fatal consequences of a cutting injury, as witnessed by Hungarian physician Ignaz Semmelweis, fundamentally changed the approach to obstetric medicine.1,2 While a staff member of the Vienna hospital Allgemeines Krankenhaus in the 1840s, Semmelweis observed epidemics of puerperal fever sweep through his obstetric wards. Those patients who were cared for by physicians were especially prone to develop the disease. These physicians, unlike the midwives, routinely performed autopsies on their deceased patients. After returning from vacation in 1847, Dr Semmelweis learned that his close colleague, Jakob Kolletschka, had died after cutting himself with a knife while performing an autopsy of a woman who had died of puerperal fever. He attended the autopsy of his friend and noted that the pathologic findings were identical to those seen in women dying of puerperal fever. He concluded that his friend had died from exposure to ‘‘cadaverous particles’’ from the deceased woman that were introduced into the body of his friend by the knife. He further concluded that these cadaverous particles could adhere to the hands of physicians and thus be transferred to the women, thereby transmitting puerperal fever. This was a revolutionary idea, because the ‘‘miasma’’ or ‘‘bad air’’ theory of hospital-acquired disease was deeply enAccepted for publication March 15, 2005. From the Department of Pathology, Fletcher Allen Health Care, Burlington, Vt. The authors have no relevant financial interest in the products or companies described in this article. Reprints: Brenda L. Waters, MD, Department of Pathology, Fletcher Allen Health Care, 111 Colchester Ave, Burlington, VT 05401 (e-mail: brenda.waters@vtmednet.org). 1022 Arch Pathol Lab Med—Vol 129, August 2005

Participants.—Pathology attending physicians, residents, dieners, and pathologists’ assistants who performed autopsies and surgical specimen examinations. Results.—Eight scalpel injuries occurred during the study period. No needle-stick injuries were reported. Searching for lymph nodes and cutting firm tissue each accounted for 3 of the injuries. Only 2 of the 8 individuals were in compliance with the departmental policy regarding protective glove wear. Hospital Report of Event forms alone failed to elicit sufficient detail regarding the mechanism of injury. Conclusions.—A laboratory-based form may be necessary to supplement the hospital form, so as to obtain full details of each injury. This information may then be disseminated to all who handle blades, with the goal of preventing future cutting injuries. (Arch Pathol Lab Med. 2005;129:1022–1026)
trenched in the medical community. Dr Semmelweis instituted a strict policy of hand washing with 4% chlorinated lime solution prior to examining any patient. What followed was a dramatic decrease in the number of his patients dying of puerperal fever. Thus, a cutting injury revolutionized medical practice. Dr Semmelweis published his findings in a landmark work, The Etiology, Concept and Prophylaxis of Childbed Fever.3 Despite vast improvements in hospital hygiene, cutting injuries still pose a significant and sometimes fatal threat to health care workers. Case reports continue to demonstrate this danger.4–6 This study attempts to address several questions concerning blade injuries: How compliant are personnel in following policies governing the use of blades? What types of cutting instruments are involved? Which hand is getting cut? What type of tissue is being processed at the time? Is a blade handle being used when injuries occur? How helpful is the hospital Report of Event form in answering these questions? The overarching intent of this study is to reduce the number of future cutting-blade injuries. This may be accomplished by identifying specific activities that result in an injury. Once identified, these maneuvers can be made known to all who use blades, with the expectation that personnel will avoid such practices if possible. MATERIALS AND METHODS
We reviewed the hospital’s Report of Event forms that were generated for every cutting injury occurring in the pathology department from March 1998 to September 2003. The information gleaned from this review was supplemented by interviews with the injured personnel whenever possible. During the same time period, we assessed the number of autopsies that were performed
Cutting Injuries in Academic Pathology—Pritt & Waters

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puncture wound/slash. or conventional knife injuries were reported. We also estimated the number of blades used. details of how the cut actually happened. An estimated 1400 scalpel blades were used each month. In 2 of these cases (cases 3 and 7). In 4 of the 7 cases in which adequate information was available. 6. thumb microtome CR gloves blade from on both handle hands * Unless noted otherwise. and in the other case (case 1). noncutting. In both instances. conventional latex or nonlatex gloves were to be worn under and over the cut-resistant glove(s). CR indicates cut-resistant glove. but the injury occurred to the cutting hand. our department instituted the requirement that its personnel use cut-resistant gloves on the noncutting hand. and the type of injury.5 cm in length) from the histology department were made available for use in the grossing room and could be mounted on handles. left Right Lymph node Yes Latex only hand search 4 Attending Right forearm Right Cutting small No Latex only physician firm tissue 5 Attending Right thumb Right Cutting small No Latex only physician firm tissue 6 Resident Right middle Unknown Lymph node Unknown Unknown finger search 7 Resident Left ring finger Right Lymph node Yes Latex only search 8 Resident Left distal Right Removing Yes Double latex. Personnel Site of Injury Cutting Hand Task Handle Used? Gloves Used? In Compliance With Glove Policy? 1 Resident Right index finger Right index finger Right Cutting placentas No Cutting cerNo vix with microtime blade 3 Resident Finger. the attending physician stated that he used excessive force. In 1 case (case 8). Ill). No one experienced more than 1 injury. In December 2001. long trimming blade. the cutting hand received the injury. Two injuries involved attending physicians. The other resident was intraoperatively assessing the depth of invasion of cervical carcinoma in a radical hysterectomy specimen (case 2). the noncutting hand wore the glove. Nor did it request information regarding whether Arch Pathol Lab Med—Vol 129. that is.5-year time period (see Table). the exact location in the hospital. pathologists’ assistants. We noted that this form consistently provided the date. and scalpel blades caused the remaining injuries. RESULTS Fletcher Allen Health Care houses an academic pathology department in which residents. allowing for further details to be obtained. requiring that cut-resistant gloves be worn on both hands. August 2005 cut-resistant gloves were worn or whether the cutting or noncutting hand was injured. for a total of 92 400 blades used during the study period. During the 5. used microtome blades (7. also a resident. incurring a cut on his dominant. and the Cutting Injuries in Academic Pathology—Pritt & Waters 1023 . Our hospital policy requires that a Report of Event form be filled out whenever there is a work-related injury or illness. However. and no information is available for the third individual. our department revised this policy. cutting hand. all in residents. The gloves are made of a high-strength polyethylene fiber (Spec-Tec. Two of the injuries came about while cutting small pieces of very firm tissue. and surgical specimens that were processed. It also elicited the site on the hands of the injury. In 1990. One resident was trying to remove the blade from the handle and cut her left (noncutting) hand. the noncutting hand received the injury. and dieners work with cutting blades and needles.Summary of Cutting Injuries* Case No. In 1 case (case 5). Peabody. He was not wearing cut-resistant gloves on either hand. Long. Niles. the resident was wearing gloves on both hands. Our laboratory used approximately 100 of these blades of each length each year. Eight cutting injuries occurred during the 5. Microtome blades caused injury in 2 of the incidents. Three of the injuries. Two injuries took place while manipulating a microtome blade. it rarely documented the exact behavior of the blade user at the time of the injury. These blades come in 13-cm and 26-cm lengths and can also be mounted on blade handles. Seven of the 8 injured individuals were available for interview. all blades used were scalpel blades. despite wearing cut-resistant gloves on both hands (case 8). Wells Lamont. and 6 involved residents. and 7). not 2 Resident Right Double latex. and NS. CR gloves on NC hand Latex only Yes No No No No Unknown No Yes specified. occurred during lymph node searches (cases 3. Cut-resistant gloves were worn in 2 of 7 cases in which glove use could be determined. Both of these 2 people were wearing latex gloves only. No needle-stick. He used a microtome blade without a handle and held the sharp edge against his hand. in this case. In addition. NS.5-year time period. No injuries were documented to occur to dieners or pathologists’ assistants. attending physicians. NC. Mass) were also provided to personnel in limited quantities. disposable trimming blades (Accu-Edge. this institution performed an average of 505 autopsies (medical examiner and hospital) and examined an average of 29 000 surgical specimens per year.

During the study period. The first injury (case 1) occurred during the period when cut-resistant gloves were required only on the noncutting hand. In the second instance (case 8). and a detailed description of the activity leading up to the injury. A suggested form to supplement the hospital’s Report of Event form. if a laboratory information system could accurately track the number and type of specimens cut by each individual.Figure 1. Salkin et al7 determined that 100% more force is required for a scalpel blade to penetrate a cut-resistant glove and 2 latex gloves than 2 latex gloves Cutting Injuries in Academic Pathology—Pritt & Waters . so as to extract all important details. had become affixed to the board by drying blood and therefore offered resistance when the resident tried to lift it up. per laboratory policy at that time. It is the general practice in this institution for residents to use handles only with microtome blades. removal of the microtome blade from its handle prompted the injury. In the process. Handles were used at the time of the injury in 3 cases. such information was not available. and 1 involved a microtome blade. the type of tissue being cut. blade slid off the tissue and cut the thumb of his cutting hand. The blade. the tip of the blade cut the index finger of her dominant. In the other case (case 4). Pathologists’ assistants and dieners use handles with both scalpel and microtome blades. Furthermore. She was wearing a cut-resistant glove only on her noncutting hand. an attending physician related that the tissue slipped. Finally. When a cutting injury is reported. there was poor compliance with the stated laboratory policy governing protective glove usage at the times when the injuries occurred. In 1 instance (case 8). may be found as Figure 1. COMMENT Most hospitals require a Report of Event form to be completed by all injured personnel. Critical information would include determination of the hand holding the blade. cut-resistant gloves were worn on both hands. then more quantitative conclusions could be made. unattached to a handle. cutting hand. and the hand not wearing the glove was cut. it remains prudent for 1024 Arch Pathol Lab Med—Vol 129. which could be used in the interview and appended to the hospital’s form. Two involved scalpel blades. and the blade flew into the air and embedded into the forearm of her cutting hand. Whether this form is filed in all cases of cutting injuries remains unknown. but the force used to remove the microtome blade from its handle was sufficient to breach all the gloves. the use of a handle. 1 injury (case 1) occurred to a resident who was picking up the scalpel blade from the cutting board while she was performing gross examinations of placentas. A suggested form. the use of cut-resistant gloves. Only 2 of the 7 individuals from whom information was available were following the policy by wearing cut-resistant gloves. August 2005 a member of the pathology department to conduct an interview with the injured individual. During the study time period. the type of blade.

One resident (case 3) did offer this reason. Another blade injury occurring outside of the study period demonstrated an unusual hazard of a scalpel handle. contrary to popular belief. These people are introduced to cut-resistant gloves at the onset of their training. These dangers include slicing the hand while trying to remove the blade (case 8) and even propelling the blade at a coworker. who have often worked many years without using them. Discard the used blade immediately. Once the blade is lifted away from the bevel. the cutting hand is also at risk for receiving an Cutting Injuries in Academic Pathology—Pritt & Waters 1025 . the steps of deploying and removing a handle are avoided. A suggested method to safely remove a scalpel blade from its handle is depicted in Figure 2. This study suggests that microtome blades may be more dangerous than scalpel blades. Used microtome blades from the histology laboratory are popular alternatives to conventional long cutting knives in our department. alone. A handle may have prevented 3 of the injuries to the cutting hand by providing greater control of the blade (cases 2. Increased experience may also have been a contributing factor.2-cm wound. Finally. The need for greater sensitivity in the fingertips may motivate residents to remove their cutresistant gloves during this activity. unlike older personnel. Certainly. given their greater cutting surface. the long. and the resident was seated and searching for lymph nodes in a colectomy specimen. avoidance of inherently dangerous maneuvers with cutting blades remains critically important. This trend is partially due to the inevitable dulling of conventional knives with use and to the lack of trained personnel to resharpen them. To safely remove a scalpel blade from its handle. B. thereby lifting the base of the blade away from the bevel. 4. Of the tasks involved in our cases. with the blade edge facing up. This may be related to their consistent use of handles. The blade penetrated his apron and surgical scrubs and Arch Pathol Lab Med—Vol 129. because they accounted for 25% of the injuries. and with the bevel of the handle facing the other hand. the latter witnessed by the corresponding author. Whether this degree of noncompliance with laboratory glove policy reflects the behavior of daily blade usage cannot be determined by this study. This injury probably would not have happened in the absence of a blade handle. A. because it is unlikely that the weight of the falling blade would have been sufficient to breach the barriers of apron and scrubs. the force generated during blade removal from a handle or during incision into firm tissue may easily exceed the protective capability of the gloves. Whether this is because of their greater safety or their decreased use cannot be determined.Figure 2. Moreover. The blade should easily detach from the handle. Anecdotal evidence suggests that compliance is higher in the younger personnel. their length makes them more cumbersome when inserting them onto a handle and also more dangerous. such as residents and pathologists’ assistants. Notable was the lack of injuries to pathologists’ assistants and dieners. and it fell onto his right thigh. removing a blade from its handle requires skill and care and is a procedure fraught with its own dangers. Moreover. and 5) and by increasing the distance between the blade and the hand (cases 2 and 5). away from all personnel. This incident involved a right-handed resident who was wearing cut-resistant gloves on both hands. Therefore. a handle would have encouraged the residents to pick up the blade by the handle rather than by the blade itself. he brushed the scalpel off the bench. At least with conventional long knives. When he reached for a paper towel. As seen by our results. The scalpel blade was attached to a handle. Notable is that no cutting injuries occurred with conventional knives. However. In cases 1 and 2. our study demonstrated that. grasp the base of the blade with the other hand and apply a force perpendicular to the long axis of the handle. August 2005 caused a 0. add a controlled force toward the end of the handle to remove the blade. the careful palpation necessary to search for lymph nodes adds further danger to the procedure by placing the palpating fingers in close proximity to the blade. firmly hold the handle in one hand. It may be that the many incisions required in the procedure contribute to the higher risk. disposable trimming blades are quite expensive. With a sturdy pair of forceps. lymph node searches appear to be especially prone to scalpel injuries. Four of the blade injuries in the study period involved the use of a blade without a handle.

121:64–66. Feller JF. great caution should be used in the vicinity of personnel wielding a blade. References 1. Based on the experience of the authors and the data obtained from this study. 2004.18:1067–1071. For this reason. Trampuz A. 8. Kummer FJ. 1026 Arch Pathol Lab Med—Vol 129. The effectiveness of cutproof glove liners: cut and puncture resistance. In: Lewis P. 4. 4. 3. because it requires multiple steps. Pierce MA. ed. When not in use. away from pools of blood. the following recommendations for safe blade usage are proffered: 1.347:1042. such as pushing the blade through the foil and folding the foil 3 times. 1996:152–154. There should be only 1 scalpel blade deployed on the cutting board at any time. As a corollary. ‘‘Mid-air collisions’’ have occurred in such settings. 6. 2. A blade should never be used to point to an object of interest in a specimen or to gesticulate in general. Lancet. Codell Carter K. Our data show that at least 50% of the injuries occurred to the cutting hand (see Table). The manner of the injury varies widely. Margotta R. thankfully. Antisepsis and asepsis. Ideally. Madison: University of Wisconsin Press. However. The Studio Italiano Rischio Occupazionale da HIV (SIROH): scalpel injury and HIV infection in a surgeon. it is important for pathology departments to keep detailed records of these incidents. 5. Johnson MD. Curry N. This will minimize the chance that the blade will slip and cause injury. A used blade should be dropped. Aust Fam Physician. 1998. 2. England: Octopus Publishing Group Ltd. Mayo Clin Proc. 1993. London. Salkin JA. Reininger R. into the sharps container. Cutting injuries are. This should never be recommended. Clin Infect Dis. such as when taking sections for histologic examination. especially when dealing with firm or rubbery tissue. departments can then educate their personnel as to what specifically are the dangerous activities associated with cutting blade use. Stuchin SA. Scalpel blades are inherently dangerous. Septic synovitis and arthritis due to Corynebacterium striatum following an accidental scalpel injury. Hospital personnel must remain cognizant of the increased danger of handling any cutting device in haste. O’Connell SJ. Simple scalpel blade holder. They should be used only when necessary. not pushed.22: 2171. It is imperative that sharps containers be emptied regularly to avoid overfilling. Hand hygiene: a frequently missed lifesaving opportunity during patient care. Education may occur during a formal orientation training session. 6.injury. Ippolito G. Cutting blades of any kind should never be used with significant force. but this study points to some activities that pose a greater risk. A new blade should be pro- cured only after the old blade has been properly discarded.27:1532–1533. Semmelweis IF. Orthopedics. The Etiology. Cone LA. 1995. 3. Schaffner W. Armed with such information. Atkinson J. 1983. August 2005 Cutting Injuries in Academic Pathology—Pritt & Waters . Wuestoff MA. other instruments. Arch Pathol Lab Med. infrequent events at this institution. scalpel blades should always be placed in clear view. Autopsy risk and acquisition of human immunodeficiency virus infection: a case report and reappraisal.79:109–116. The cutting effect of the tool is best obtained by sliding the blade back and forth rather than pushing it through the tissue. 1997. fashioning a scalpel blade handle out of aluminum foil8 is inherently dangerous. dexterity and sensibility. Widmer AF. 8. History of Medicine. We recommend that blades be set at the far right or left corner of the cutting board. Concept and Prophylaxis of Childbed Fever. 5. trans-ed. Blunt manual dissection and scissors should be used in all steps of prosection and dissection unless it is absolutely necessary to use a scalpel. O’Halloran L. 1996. 7. 7. this will reduce the incidence of injuries in the future. and tissue. Whether using a blade handle is safer than not using it is still not determined.

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