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BIOLOGICAL ENERGY HAZARD - Coggle Diagram
BIOLOGICAL ENERGY HAZARD
What Happened
During the post treatment consultation the dentist brushed their elbow against the unsheathed contaminated ultrasonic scaler tip and suffered subcutaneous injury to the inner forearm.
After performing a professional clean on a patient, who had disclosed their positive HIV status on their medical form the provider push aside their instrument tray to consult with the patient.
After completing the consultation in regards to the patients oral health and checking patient out the provider went to the hospital for treatment requried.
Why it Happened
The provider had their back to the instrument tray and couplings and wasn't able to determine how close the instruments were to the providers arm.
The provider swung their arm and it made contact with the ultrasonic scaler tip, and the force behind the movement was enough for the ultrasonic scaler tip to penetrate the skin.
The general professional clean instrument tray can contain 5 sharps: the ultrasonic scaler tip, the sickle probe and 3 x hand scalers.
The position of the ultrasonic scaler coupling (attachment) was still upright (vertical) with the scaler tip was pointing outward (away from the tray).
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System failures
Communication
Within the complex nature of this system there are two people working together to perform treatment on a third party. There needs to be clear communication and understanding of ones duties for this to be achieved. .
The provider of care was new to both the country and the clinic. This could mean certain rules and regulations may have been miscommunicated during the induction process, in regards to the responsibilities of sharps disposal. Providers may work in several different practices where policy and procedure and staff skill sets may differ from one practice to another
Procedure
The company procedure was for the dentist to remove all sharps and place them on tray to be processed and place any disposable sharps in the designated biohazard sharps container. The nurse is to them remove all paper products into the surgery bin and take the tray through to processing. Then change over the room ready for next patient
The dentist failed to sheath (place guard on) the scaler tip, and remove it from the coupling device. Resulting in injury subcutaneous penetrative injury.
Environment
In the surgery where the incident occurred, the dentist had pushed the tray table aside (into an enclave for the door) and positioned themselves to face the patient. Mean the nurse was unable to access the instruments to contain them with a tray lid.
The dentist has position themselves in a way that they were blocking the nurse from cleaning accessing the tray table and collecting the instrument tray (where the contaminated instruments would be). This resulted in an contaminated
sharp instrument being left in an exposed position.
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