Authors (including presenting author) :
CHU YY(1),NGAN WK(1), KWOK LF(1), LEUNG SCC(1), TAM YK(1),WONG M(1), NG ML(1), LEE CK(2),KO SM(2),LEUNG H(3),HO MN(3)
Affiliation :
(1)Operating Theatre, Tuen Mun Hospital, (2)Central Sterile Supplies Department, Tuen Mun Hospital, (3) Operating Theatre, Pok Oi Hospital
Introduction :
Dental swab is one of the sponges used in Tuen Mun Hospital Operating Theatre (TMH OT) for absorbing blood, applying pressure and dissecting tissue. Scrub nurses need to cut the dental swab into various sizes for surgeons during the operation. This long-standing practice has been performed in our department until a near miss incident happened where there was a discrepancy between cutting dental swab number on surgical field and counting record. It was a wake-up call for us as this practice has a potential risk of unintentional retention of a foreign body.
Objectives :
Revise dental swab counting practice in TMH OT to enhance the patient safety from unintentional retention of foreign bodies.
Methodology :
1. Dental swab packaging, counting record method and practice of using dental swab are planned to improve:
- Revamp the quantity, size and package of dental swab.
- Revise the guidance on using and recording dental swab.
2. Educational sessions on revising dental swab counting practices for OT nurses are provided between Nov to Dec, 2018. Reminder notices of dental swab counting practices revision are displayed in OT.
3. Revised dental swab counting practice and new packages are launched in mid-Dec, 2018.
4. Likert scale questionnaire are applied to assess the nurses’ perception and adaptation to the new practice and packaging in Feb, 2019. After implementation of the new practice, observations are conducted to identify other possible areas for improvement.
Result & Outcome :
- 100% nurses have attended the educational sessions.
- By now, there is no episode of discrepancy between the number of dental swab on surgical field and counting record.
- 60 questionnaires were distributed and response rate was 100%. Over 90% nurses found that the new practices are easy to adapt, and agreed that it is possible to decrease the chance of retained foreign bodies. 95% nurses reflected that the revised practice conduce to operations running smoothly and efficiently.
- Staff’s positive feedback and acceptance reflect their compliance of this new practice. It is important to prevent miscounts, and thus lower the chance of retained foreign body during operations and maintain patient safety.
- Lastly we standardize this practice in NTWC operating theatres in 3Q, 2019.
