accountability for sponges, sharps and other instruments

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					Accountability for Sponges,              Policy # 0100
Sharps and Instruments



1.    PURPOSE.

1.1   To provide guidelines of accountability for sponges, sharps and
      instruments used during a surgical procedure. To provide safe practice for
      the surgical patient, prevent patient injury and adhere to legal

2.    POLICY.

2.1   All counts shall be audibly and visually performed according to procedure.

2.2   Incorrectly numbers packages of sponges and sharps shall be isolated and
      not used during the procedure.

2.3   The Circulating Nurse and scrub person shall document the operative record
      with the results of the counts.

2.4   For instruments having more than one part, the total number of parts shall
      be accounted for.

2.5   Counts not done due to patient emergency shall be documented on the
      operative record and incident report filed.

2.6   If the count is incorrect, the surgeon is notified, a recount is taken, a
      search is made for the missing item and, if not found, an x-ray of the
      patient is taken. If the item is not found on x-ray, documentation of x-
      ray results is recorded on the operative record. If x-ray indicated item
      is in the patient, document this fact and the course of action taken.

2.7   Patients are not to leave the OR until missing items are accounted for.

2.8   Raytec sponges are never to be utilized as packing or dressing.


3.1   All counts shall be taken before the procedure, when additional
      sponges/sharps/instruments are added to the sterile field, prior to
      closure of a cavity, prior to wound closure, and when permanent relief of
      the scrub person and/or Circulating Nurse occurs.

3.2   All counts will be performed by two (2) people, one (1) of which is an RN.

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3.3   Counts shall always begin at the surgical field and surrounding area, then
      to the Mayo stand, then to back table and lastly, the sponges, sharps or
      instruments are discarded from the field.

3.4   Sponges shall be counted on all procedures involving a large body cavity.

      3.4.1 Sponges shall be counted in the OR prior to, during, a s n
Description: policies and protocols for infection control, the prevention of infection, the ability to demonstrate extreme measures are taken to prevent the cause of infection in and around the workplace. This protocol is geared more towards the surgical setting but can be customized to meet any health care setting as most of them are universal precautions based policies.
PARTNER Compliance  Doctor
THE COMPLIANCE DOCTOR, LLC is a consulting firm that offers services to assist health care professionals at the task(s) of state licensing, National Accreditation, as well as Medicare Certifications in any outpatient, ambulatory type of business. We assist the client by providing them leadership and consultation along the labored process of the regulatory world in health care. There is never a job too small, nor too big, we can handle them all.