2. I. Problem Identification
Used surgical needles, soiled padding
and sponges found in the hamper of soiled
linens.
3. II. Define the problem
A surgical needle with suture is a medical
device used to hold body tissues together
after an injury or surgery. It generally
consists of a needle with an attached
length of thread. Used needles and sutures
refer to the consumption of such materials
according to their limit or purpose.
4. A surgical sponge is a specialized sponge or pad
used in surgery. A surgical sponge is used to absorb
liquids from a surgical site. It may be used in
combination with suction to keep a surgical site
clear, by a surgeon working to control bleeding,
and in a number of other applications. Like other
things used in surgery, surgical sponges are
designed to be sterile; they come in their own
sterile packaging and can be safely autoclaved.
They are generally disposable and discarded after
surgery into biohazard containers after surgery.
5. Padding is wide sheet of thin absorbent
cotton layers placed under the operative
site to avoid spillage of bodily fluids and
to monitor for any discharges. Soiled
Paddings and surgical sponges refer to
unclean or contaminated paddings and
surgical sponges which cannot be used for
its purpose.
6. Hamper is a container where soiled
linen are placed.
Used surgical needles, soiled padding
and sponges are disposable consumables
that were used in an operation that were not
properly disposed.
7. III. Verification of the Problem
The problem regarding proper segregation
was recognized last April 7, 2011 wherein the
laundry on duty during the A.M. shift found a
Chromic 2/0 needle with suture on the hamper of
soiled linens.
A memo was released followed by
counseling of the staff regarding the incident.
8. An encountered with the repeated incident
that happened last May 4, 2011 brought
about a released of memo regarding
counseling of the OR staff involved wherein
a Chromic 3/o needle with suture was found
together with an unsegregated soiled padding
which was seen on the hamper of soiled
linens. The OR staff on duty during the 24
hours shift was orally reprimanded and
counseled.
9. IV. Problem Statement
Surgical needles, soiled padding and
sponges found in the hamper of soiled
linens.
10. V. Specifically, the team seeks to answer the
following questions:
• What are the possible causes of deficiency of
the segregation of needles with suture,
padding and sponges?
• What are the actual effects encountered by the
repeated incident of and other possible
problems that might be encountered when a
repeated incident occurs.
11. Staff gets sick; call informing abt. An Staff resigning/ policy
emergency situation, low census of pt.,
Fast turn over/rotation
of the
Has an pulled out to other area
hospital/premature
appointment rotation
Lack of skilled
Needs
LOA//EL/SL/PO Under staff staff/Under
not Importance
Wants to go trained
recogn not seen
home
Understaffed ized
during double Numerous cases Not
table scenario with limited required
Scrub nurse man power
staff in a Piled up soiled inst.
hurry /needles with No written
suture/sponges/infect guidelines
Work overload
ious waste
Not a
Tired Attitude
Another staff general
problem
initiates cleaning practice
inst. and infectious
waste disposal
Lazy Overconfident No. of
needles not
Unawareness of shouted
the # of needles Staff misses needle/s with before
with suture and suture, sponge/s, padding and disposal to
sponges puts waste to hamper container
Used surgical needles, soiled padding and sponges in the hamper of soiled linens
12. Hospital policy, cost
Needs cutting, emergency
not leave
recogn Importance
ized not seen
Pulled out, on leave, Pull in / pull out
only 3 N.O.D every system not fully
Sunday implemented
No written Instructors Varied
guidelines/instructions are not interest/priority
or program about the trained
procedure Not enough
people are
Under staff trained
Varied reasons in during
giving instruction double table
No formal
Preferred
orientation even Fast turn over
other area Rotation not
to senior nurse
Lack of man implemented
power when before
Varied verbal
double table Staff resigning
instruction
Not oriented Resistance to
by senior rotation
Lack of Confused Needs not
nurse
interest In a hurry to recognized
finished task
Personal issues
OR staffs unaware of the Importance
procedure not seen
(Proper segregation) Inefficient to perform task Attitudes
Used surgical needles, soiled padding and sponges in the hamper of soiled linens
13. Used surgical needles, soiled padding and sponges in the hamper of soiled linens
Staff pricked while Job
Delayed
inspecting soiled linens Oral reprimand loss
salary
Hospital
license on-
hold/penalized
Potentially life-threatening Decline Possible
Written reprimand
diseases acquired by staff in in clients hospital
contact with infectious closure
waste
Suspension
Cross
contamination
between staff Termination
and patient
14. VI. Objectives
1. To have based program and instructions in the
process on how the O.R. staff nurses segregate
infectious waste after the operation.
2. Quality work output.
VII. Potential solutions
1. Develop a training manual about proper waste
disposal after operation.
2. To have more trained, competent, and efficient O.R.
staff
15.
16. Documented procedure and policies on proper waste disposal after the operation
Strategies Activities Indicators PR TF
1.1 Review old 1.1 Retrieve all documents Documented policies and
procedures and policies if any procedures
on proper waste Notation on the reviewed
disposal after the 1.1.2 Review the old policies policies and procedures
operation and procedures
1.2 Document verbal 1.2.1 Put into writing the Brainstormed written
procedures in proper verbal procedures work instructions
waste disposal after the
operation
1.3 Revise or create new 1.3.1 Create/ revise new Constructed new/ revised
policies and procedures policies and procedures policies and procedures
1.3.2 Present and compare MOM
the old policies and the
newly constructed/ revised
policies to HA/ QMS for
approval
17. 1.4 Disseminate the 1.4.1 Compile the draft Documented draft policies
approved policies and approved policies and and procedures
procedures procedures
1.4.2 Set a meeting among Schedule of meeting
the OR staffs. MOM
1.4.3 Discuss the approved
policies and procedures to
the OR staffs.
1.5 Pilot test the 1.5.1 Implement the draft OR& Admin
approved policies and approved policies and
procedures procedures
1.5.2 Present the results to Results report
HA
1.6 Documented policies 1.6.1 forward the approved Documented procedures
and procedure on policies and procedures to and policies
proper safekeeping of QM for proper
regulators documentation
1.6.2 file and secure the Documented file
official document
1.6.3 Implement the
approved and official
policies and procedures on
proper waste disposal
18. Quality work output
Strategies Activities Indicators PR TF
4.1 Assess/ review work 4.1.1 Retrieve files (201 and
performance for the year other memorandums)
2010 up to present 4.1.2 Request for job evaluation
summary report at HR for
concerned employee
4.1.3 Make an assessment
summary report
4.1.4 Forward assessment
summary report to HR
4.2 HR recommends needed 4.2.1 HR formulates intervention
intervention program
4.2.2 HR presents recommended
intervention program to HA/ QMS
4.3 Work quality and attitude 4.3.1 HR conducts intervention
reflection program program
4.3.2 Assess intervention results
and present to HA
