I. Problem Identification Used surgical needles, soiled paddingand sponges found in the hamper of soiledlinens.
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.
A surgical sponge is a specialized sponge or padused in surgery. A surgical sponge is used to absorbliquids from a surgical site. It may be used incombination with suction to keep a surgical siteclear, by a surgeon working to control bleeding,and in a number of other applications. Like otherthings used in surgery, surgical sponges aredesigned to be sterile; they come in their ownsterile packaging and can be safely autoclaved.They are generally disposable and discarded aftersurgery into biohazard containers after surgery.
Padding is wide sheet of thin absorbentcotton layers placed under the operativesite to avoid spillage of bodily fluids andto monitor for any discharges. SoiledPaddings and surgical sponges refer tounclean or contaminated paddings andsurgical sponges which cannot be used forits purpose.
Hamper is a container where soiledlinen are placed. Used surgical needles, soiled padding and sponges are disposable consumables that were used in an operation that were not properly disposed.
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 bycounseling of the staff regarding the incident.
An encountered with the repeated incidentthat happened last May 4, 2011 broughtabout a released of memo regardingcounseling of the OR staff involved whereina Chromic 3/o needle with suture was foundtogether with an unsegregated soiled paddingwhich was seen on the hamper of soiledlinens. The OR staff on duty during the 24hours shift was orally reprimanded andcounseled.
IV. Problem Statement Surgical needles, soiled padding andsponges found in the hamper of soiledlinens.
V. Specifically, the team seeks to answer thefollowing 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.
Staff gets sick; call informing abt. An Staff resigning/ policy emergency situation, low census of pt., Fast turn over/rotation of theHas an pulled out to other area hospital/prematureappointment rotation Lack of skilled Needs LOA//EL/SL/PO Under staff staff/Under not ImportanceWants to go trained recogn not seenhome Understaffed ized during double Numerous cases Not table scenario with limited requiredScrub nurse man powerstaff 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
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 implementedNo written Instructors Variedguidelines/instructions are not interest/priorityor program about the trainedprocedure 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 issuesOR staffs unaware of the Importanceprocedure not seen (Proper segregation) Inefficient to perform task Attitudes Used surgical needles, soiled padding and sponges in the hamper of soiled linens
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 reprimanddiseases acquired by staff in in clients hospital contact with infectious closure waste Suspension Cross contamination between staff Termination and patient
VI. Objectives1. 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 solutions1. Develop a training manual about proper waste disposal after operation.2. To have more trained, competent, and efficient O.R. staff
Documented procedure and policies on proper waste disposal after the operation Strategies Activities Indicators PR TF1.1 Review old 1.1 Retrieve all documents Documented policies andprocedures and policies if any procedureson proper waste Notation on the revieweddisposal after the 1.1.2 Review the old policies policies and proceduresoperation and procedures1.2 Document verbal 1.2.1 Put into writing the Brainstormed writtenprocedures in proper verbal procedures work instructionswaste disposal after theoperation1.3 Revise or create new 1.3.1 Create/ revise new Constructed new/ revisedpolicies 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
1.4 Disseminate the 1.4.1 Compile the draft Documented draft policiesapproved policies and approved policies and and proceduresprocedures 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& Adminapproved policies and approved policies andprocedures procedures 1.5.2 Present the results to Results report HA1.6 Documented policies 1.6.1 forward the approved Documented proceduresand procedure on policies and procedures to and policiesproper safekeeping of QM for properregulators 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
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