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A System-Wide Initiative to Prevent Retained Vaginal Sponges

Chagolla, Brenda A. MSN, RN, CNS; Gibbs, Verna C. MD; Keats, John P. MD; Pelletreau, Barbara MPH, RN

MCN: The American Journal of Maternal/Child Nursing: September-October 2011 - Volume 36 - Issue 5 - p 312–317
doi: 10.1097/NMC.0b013e31822ab204
Feature Article

As any perinatal nurse knows, retained vaginal sponges are an obstetrical and postpartum patient safety problem. As surgical sponge counts are not routine in some obstetrical units for vaginal births, our healthcare system chose to institute a rigorous process to eliminate retained sponges in all vaginal births. This article describes this process, along with the lessons learned, when Catholic Healthcare West implemented the Sponge ACCOUNTing System in its 32 hospitals in California, Arizona, and Nevada. Implementation of this process involved the standardization of practice for obstetricians, certified nurse midwives, nurses, obstetric technicians, radiologists, and radiology technicians in the management and accounting of surgical sponges.

This QI project was aimed at eliminating the problem of retained vaginal sponges after vaginal births.

Brenda A. Chagolla is a Perinatal Clinical Safety Specialist at Catholic Healthcare West, Rancho Cordova, CA. She can be reached via e-mail at

Verna C. Gibbs is the Director at NoThing Left Behind and the Professor of Surgery, UCSF, San Francisco, CA.

John P. Keats is the President at California HealthFirst Physicians, Camarillo, CA.

Barbara Pelletreau is the Vice President Patient Safety & Clinical Risk at Catholic Healthcare West, Rancho Cordova, CA.

The authors have disclosed that there are no financial relationships related to this article.

© 2011 Lippincott Williams & Wilkins, Inc.