QUALITY IMPROVEMENT ACTIVITY

I. Problem Identification

Used surgical needles, soiled padding and sponges found in the hamper of soiled linens.

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 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.

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.

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.

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.

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.

IV. Problem Statement Surgical needles, soiled padding and sponges found in the hamper of soiled linens.

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.

Has an appointment

Staff gets sick; call informing abt. An emergency situation, low census of pt., pulled out to other area

Fast turn over/rotation

LOA//EL/SL/PO Wants to go home Understaffed during double table scenario Scrub nurse staff in a hurry

Under staff

Lack of skilled staff/Under trained

Staff resigning/ policy of the hospital/premature rotation Importance not seen

Needs not recogn ized

Numerous cases with limited man power

Not required

Piled up soiled inst. /needles with suture/sponges/infect ious waste

Work overload

No written guidelines

Another staff initiates cleaning inst. and infectious waste disposal

Tired

Attitude problem

Not a general practice

Lazy Unawareness of the # of needles with suture and sponges

Overconfident

Staff misses needle/s with suture, sponge/s, padding and puts waste to hamper

No. of needles not shouted before disposal to container

Used surgical needles, soiled padding and sponges in the hamper of soiled linens

Needs not recogn ized

Hospital policy, cost cutting, emergency leave Importance not seen Pulled out, on leave, only 3 N.O.D every Sunday Pull in / pull out system not fully implemented

No written guidelines/instructions or program about the procedure

Instructors are not trained

Varied interest/priority Not enough people are trained

No formal orientation even to senior nurse

Varied reasons in giving instruction Preferred other area

Under staff during double table Rotation not implemented before

Fast turn over

Varied verbal instruction Not oriented by senior

Lack of man power when double table

Staff resigning Resistance to rotation

nurse

Lack of interest

Confused In a hurry to finished task

Needs not recognized Personal issues Importance not seen

OR staffs unaware of the procedure (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 inspecting soiled linens

Oral reprimand Hospital license onhold/penalized Written reprimand

Delayed salary

Job loss

Potentially life-threatening diseases acquired by staff in contact with infectious waste

Decline in clients

Possible hospital closure

Suspension Cross contamination between staff and patient

Termination

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

Documented procedure and policies on proper waste disposal after the operation
Strategies
1.1 Review old procedures and policies on proper waste disposal after the operation

Activities
1.1 Retrieve all documents if any

Indicators

PR

TF

Documented policies and procedures Notation on the reviewed 1.1.2 Review the old policies policies and procedures and procedures Brainstormed written work instructions

1.2 Document verbal 1.2.1 Put into writing the procedures in proper verbal procedures waste disposal after the operation 1.3 Revise or create new 1.3.1 Create/ revise new policies and procedures policies and procedures 1.3.2 Present and compare the old policies and the newly constructed/ revised policies to HA/ QMS for approval

Constructed new/ revised policies and procedures MOM

1.4 Disseminate the approved policies and procedures

1.4.1 Compile the draft approved policies and procedures 1.4.2 Set a meeting among the OR staffs. 1.4.3 Discuss the approved policies and procedures to the OR staffs. 1.5.1 Implement the draft approved policies and procedures 1.5.2 Present the results to HA

Documented draft policies and procedures Schedule of meeting MOM

1.5 Pilot test the approved policies and procedures

OR& Admin

Results report

1.6 Documented policies and procedure on proper safekeeping of regulators

1.6.1 forward the approved Documented procedures policies and procedures to and policies QM for proper 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 4.1 Assess/ review work performance for the year 2010 up to present Activities 4.1.1 Retrieve files (201 and other memorandums) 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 Indicators PR TF

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

THANK YOU!!!