I. ABSTRACTII. INTRODUCTIONIII. PROBLEM IDENTIFICATION AND PRIORITIZATION

A. LIST OF PROBLEMS

1. Incorrect E-cart inventories or other inventories2. Delayed BCG vaccine given to newborns3. Hand hygiene practices are not followed4. Delayed endorsement5. Nurses not following sterile technique principles6. Lack of 7S compliance7. Lack of infection control compliance causing IV infiltration8. Transport of patient through the canteen9. Improper arrangement of nurse’s progress notes10. Sterilium vs. sterility

B. PROBLEM OR CAUSE

LIST OF PROBLEMS PROBLEM (P) OR CAUSE (C)1. Incorrect E-cart inventories or other inventories CAUSE2. Delayed BCG vaccine given to newborns PROBLEM3. Hand hygiene practices are not followed CAUSE4. Delayed endorsement PROBLEM5. Nurses not following sterile technique principles PROBLEM6. Lack of 7S compliance PROBLEM7. Lack of infection control compliance causing IV infiltration

PROBLEM

8. Transport of patient through the canteen PROBLEM9. Improper arrangement of nurse’s progress notes CAUSE10. Sterilium vs. sterility CAUSE

C. CONTROLLABILITY OF THE PROBLEM

LIST OF PROBLEMS CONTROLLABILITY(C-Controllable, U-Uncontrollable, I-Interface)

1. Delayed BCG vaccine given to newborns C2. Delayed endorsement C3. Nurses not following sterile technique principles C4. Lack of 7S compliance C5. Lack of infection control compliance causing IV infiltration

C

6. Transport of patient through the canteen I

D.VERIFICATION OF THE EXISTENCE OF THE PROBLEM

LIST OF CONTROLLABLE PROBLEMS INITIAL DATA COLLECTED1. Delayed BCG vaccine given to newborns We observed that before giving BCG vaccine

to newborns, they will wait 10 babies to be delivered first.

2. Delayed endorsement Generally, endorsement happens 15 minutes before the shift, however we observed that it’s not being followed due to the reason that some of the staffs for the next shift are late.

3. Nurses not following sterile technique principles In the OR we observed that some of the sterile technique principles are not followed by some nurses.

4. Lack of 7S compliance We have observed in the inpatient units that some principles of 7s is not strictly followed like systematic arrangement because some of the charts are not correctly arrange and not in place.

5. Lack of infection control compliance causes IV infiltration

We have observed that the infection control sheets are not being updated and the due date for changing the IV line is not being followed. In the inpatient units,___/12 patients had cases of infiltration.

E. CLASSIFICATION OF PROBLEMS ACCORDING TO SIGNIFICANCE

LIST OF CONTROLLABLE PROBLEMS

INITIAL DATA COLLECTED SIGNIFICANCE ACTION TAKEN

1. Delayed BCG vaccine given to newborns

We observed that before giving BCG vaccine to newborns, they will wait 10 babies to be delivered first.

SIGNIFICANT GO

2. Delayed endorsement Generally, endorsement happens 15 minutes before the shift, however we observed that it’s not being followed due to the reason that some of the staffs for the next shift are late.___/___ instances that endorsement is delayed.

SIGNIFICANT GO

3. Nurses not following sterile technique principles

In the OR we observed that some of the sterile technique principles are not followed by some nurses.

SIGNIFICANT GO

4. Lack of 7S compliance We have observed in the inpatient units that some principles of 7s is not strictly followed like systematic arrangement because some of the charts are not correctly arrange and not in place.

SIGNIFICANT GO

5. Lack of infection control compliance causes IV infiltration

We have observed that the infection control sheets are not being updated and the due date for changing the IV line is not being followed. In the inpatient units, ___/12 patients had cases of infiltration.

SIGNIFICANT GO

F. PRIORITIZATION OF THE PROBLEM

LIST OF SIGNIFICANT PROBLEMS CRITERIA TOTAL RANKA B C D E

1. Delayed BCG vaccine given to newborns 4.8 3 3 2 2.6 15.4 42. Delayed endorsement 2.8 2 3 2 3 12.8 53. Nurses not following sterile technique principles

5 4.4 4 5 5 23.4 2

4. Lack of 7S compliance 3.2 4 3 5 5 20.2 35. Lack of infection control compliance causes IV infiltration

5 5 4.4 5 5 24.2 1

CRITERIA

A – MEDICAL/CLINICAL IMPORTANCEB – SOCIAL IMPORTANCEC – ?D – EFFECTIVENESS OF THE CURRENT USE METHODE – FEASIBILITY

G. PRIORITY PROBLEM:

Lack of infection control compliance causes IV infiltration

H. TENTATIVE PROBLEM STATEMENT: