KANABEC HOSPITAL MORA MINNESOTA DATE JANUARY 2008 SUPERCEDES NEW

KANABEC HOSPITAL MORA MINNESOTA DATE JANUARY 2008 SUPERCEDES NEW
KANABEC HOSPITAL MORA MINNESOTA DATE SEPTEMBER 2006 SUPERSEDES 1104



ROUGH DRAFT

KANABEC HOSPITAL

MORA, MINNESOTA


DATE:

January 2008

SUPERCEDES:

New



ORIGINATOR (Dept):

OB


DESTINATION DEPARTMENTS:

ED, Med/Surg









PREVENTION OF UNINTENDED FOREIGN OBJECT RETENTION IN VAGINAL EXAM



  1. PURPOSE


Eliminate the risk of unintended foreign object retention in obstetrical/vaginal examinations after post procedure.



  1. POLICY


Those individuals participating in obstetrical/vaginal procedures (i.e., vaginal deliveries, vaginal exams) are responsible for utilizing and documenting sponge counts, suture and needle counts pre and post procedure, and in addition, following the outlined procedure in case of discrepancy.



  1. PROCEDURE


    1. Obstetric Department / Med-Surg

      1. Only radiopaque sponges will be utilized for vaginal/obstetrical exams.


      1. Initial counts for sponges, vaginal packing, sutures and needle will be completed prior to patient use.


      1. The initial count will be documented by an RN on the “Sponge Count Assessment”. The count will be witnessed by a second staff member.


      1. If additional items (sponges, packing, sutures, needles) are needed during the procedure, those items will be entered into the “Sponge Count Assessment.”


      1. The Health Care provider performing the procedure will place used sponges or packing in designated area. Sharps will be placed in designated area.


(continued)

Prevention of Foreign Object Retention in Vag. Exam

Page 2


III. Procedure, continued


    1. Post Procedure/Post delivery

  1. As soon as possible after completion of the procedure, post counts will be done for sponges, vaginal packing, sutures and needles.


  1. The final count will be entered into the Sponge Count Assessment


  1. Post counts will be completed by an RN and a second staff member.


    1. Discrepancy of Sponge Counts

  1. If a discrepancy is noted in the counting process, the physician will be informed of the discrepancy.


  1. The physician may choose to perform a vaginal inspection for unintentionally retained foreign object or to request a radiographic image to rule out retained foreign object.


    1. Emergency Department

  1. The potential for vaginal exams utilizing sponges in the Emergency Department may occur.


  1. The pre-procedure/during exam, post-procedure, and discrepancy guidelines will remain the same in the Emergency Department with the exception of the documentation will be completed on a written form.

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