Description of Event or Problem · 1
ORAL SWAB STICK WAS USED TO COMPLETE ORAL CARE ON PATIENT. WHEN RN REMOVED THE SWAB, THE SPONGE END REMAINED IN THE BACK OF THE PATIENT'S MOUTH. RN REQUIRED ASSISTANCE TO HOLD PATIENT'S HEAD STILL, USE A LIGHT AND EXTRACT THE SPONGE END WITH TWEEZERS FROM THE BACK OF THE PATIENT'S MOUTH. PATIENT IS INTUBATED AND VENTILATED. SWAB WAS REMOVED WITH NO DAMAGE/HARM TO THE PATIENT. THE SWAB FROM THIS EVENT WAS DISCARDED, BUT THE 3 REMAINING DENTIP ORAL SWABS WERE RETAINED AS WELL AS THE OUTER PACKAGING FOR THE ORAL PACK. ONE ORAL SWAB WAS OPENED FOR INVESTIGATION BY CLINICAL ENGINEERING. THE ADHESIVE BETWEEN THE PLASTIC STICK AND SPONGE DID NOT APPEAR TO HAVE ANY GAPS INITIALLY. WITH A SMALL AMOUNT OF ROTATING AND PULLING FORCE FOR APPROX. 30 SECONDS, THE SPONGE BECAME DETACHED FROM THE PLASTIC HANDLE. IMAGES OF THE HANDLE CAN BE VIEWED UNDER ATTACHMENTS. IT APPEARS THAT ADHESIVE IS ONLY PRESENT ON ONE SIDE OF THE PLASTIC HANDLE. PER SITE REPORTER: MANUFACTURER REPRESENTATIVE WAS EMAILED, AWAITING RESPONSE. WE HAVE THE REMAINING DENTIP SWABS FROM THE SAME PACK, BUT NOT THE BROKEN SWAB FROM THIS EVENT. SWABS AND OUTER PACKAGING WILL BE GIVEN DIRECTLY TO MEDLINE REP.