NeedleStick Injury Case Scenario 3

At around 7:30 PM, the staff was transferring all sterile instruments from an operating
room theatre to the newly renovated instrument room at the complex.

As she was transferring and rearranging doctor's owned instruments to a certain

location in the instrument room, a percutaneous introducer needle

(about 5-6 inches in length) inadvertently perforated the double pouch container. Her
left palm was hit by the introducer needle.

DECODE
A. Describe

- The nurse is transferring all sterile instruments around 7:30pm

- There is a newly renovated instrument room.

- The nurse is rearranging loose doctor's owned instruments.

- The percutaneous introducer needle inadvertently perforated the double pouch

container.

B. Explore

- It may be the nurses 5th day of duty.

- The nurse's shift is 6:00 am to 6:00 pm and was asked to extend and accomplish the
pending task.

- The nurse is excited to go home and rushes to complete tasks.

- The nurse may not be familiar to the set up of the newly renovated instrument room.

- The loose sterile instruments are not organized and separated. (Sharps and blunt)
C. Communicate

- If the nurse coordinated with his/her immediate superior, charge nurse or instrument
technician on proper handling of instruments then the needle stick injury must have
been prevented.

Example: The circulating nurse reminds the scrub nurse that she had loose sharp
instruments. The circulating nurse reiterates to be careful.

D. Do

- Ask the charge nurse or immediate superior for the orientation to the newly renovated
instrument room.

- The nurse should have separated the loose instrument to it's designated categories.

- Focus and presence of mind must be always observed in everything the nurse does.

E. Evaluate

- Coordinate with the instrument technician on producing a puncture proof needle edge
protector or other better means of packaging.

- Coordinate with co-staff nurses and other health care providers in the awareness of
needle stick injury.
Root Cause Analysis (FISH BONE)
Topics:

1. Environment

- Newly renovated instrument room (Unfamiliarity)

- Lighting

- New instrument placement

- Not conducive

2. People

- Unorganized staffing?

- Not coordinating with the (Charge nurse, Cube, and Instrument technician)

- Complaisant nurse

- Incompetent nurse

3. Training

- Untrained nurse

- Hasn't attended orientation regarding newly renovated instrument room

- Untrained instrument technician

4. Instrument

- No sharp's/needle's edge cover or protector

- No sharp's/needle's puncture proof container

Effect: Improper handling of instrument

 Perioperative Nursing Program
St. Luke’s Medical Center – Global City

Needlestick Injury
Prevention

Group 1

Albasin, Darwin
Arriola, Ann Margaret
Bella, Sheryn
Viola, Luis Alfredo