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Patient 1
A NASOPHARYNGEAL SWAB BROKE OFF AT THE TRANSITION POINT WHERE THE SHAFT CHANGES FROM THIN TO THICK IN (B)(6) ON (B)(6) AT PEDIATRICS. TWO NURSES WERE THERE FOR THE INCIDENT, ONE WAS PERFORMING NASOPHARYNGEAL COLLECTION WHILE THE OTHER WAS HOLDING THE CHILD LAYING IN THE SUPINE POSITION. SWAB WAS ROTATED MULTIPLE TIMES [DURING A SONG OF THE ABC'S - IN WHICH THE NURSE REACHED THE END OF THE ALPHABET BUT HAD NOT YET FINISHED THE SONG] FOR A TOTAL OF 10 SECONDS BEFORE THE NURSE FELT THE GIVE IN THE SWAB - INDICATING THE BREAK. THE CHILD WAS CRYING, BUT NOT THRASHING. WHEN THE SWAB BROKE, THE END STILL INSIDE THE PT WAS NOT VISIBLE. IT IS INDICATED IN THE DOCUMENTATION FROM THE ED THAT THE CHILD JERKED AND THAT IS WHEN THE SWAB BROKE. AFTER THE INCIDENT, THE CHILD DID NOT COUGH, GAG, OR APPEAR TO BE DISTRESSED IN ANY WAY. AS OF (B)(6), THE MOTHER CONFIRMED THAT THE CHILD HAD NOT COUGHED OUT THE SWAB OR PASSED IT IN HER STOOL. PT HAD A F/U APPOINTMENT ON (B)(6) BUT IT WAS AN ALREADY SCHEDULED APPOINTMENT AND WAS NOT IN REGARDS TO THE SWAB INCIDENT.