Programme Aim

To reduce the incidence of retained swab ‘never’ events to zero within 36 months of the start of the project; to ensure a robust procedure is in place for the checking and accounting of swabs/red strings in a variety of clinical procedures and situations. A partnership between the Oxford AHSN and Oxford University Hospitals NHS FT which may be adopted by secondary care providers across the Oxford AHSN region.

Programme Focus

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. CCGs are required to monitor the occurrence of never events within the services they commission and publicly report them on an annual basis.

Programme Details

Maternity Never Event Project detailRetained swabs can lead to fever, infection, pain, haemorrhaging and psychological problems. They are errors which should never happen.

A reliable handover of swabs from delivery suite to theatres when women are transferred for a manual removal of placenta, suturing or examination under anaesthetic began in February 2016.

The project employs Institute for Health Improvement (IHI) methodology to test interventions directed towards standardising the following processes:

  • swab counts at birth
  • handover of swabs from delivery suite to theatres
  • known swabs left in-situ from theatres to observation area/delivery suite
  • swab counts at suturing
  • documentation of swab counts

The project will also focus on interventions towards availability of designated scrub practitioners.

The first test of change commenced on 1 February 2016 focusing on standardising the process of handover of swabs from delivery suite to theatres – introducing a bag into the birthing packs which swabs are put in if transferred to theatre

  • Reducing Never Events of Retained Swabs – driver diagram
  • SPC Chart 1 – noting the adherence of 3 aspects of the swab policy when transferring a woman from delivery suite to theatre with a swab in situ including a verbal and written handover
  • SPC Chart 2 – noting the verbal handover of swab count to theatre staff
  • SPC Chart 3 – noting the written handover of swab count to theatre staff
  • SPC Chart 4 – noting the days between near miss events (a near miss event is where there is no verbal or written handover of a swab that is in situ upon transfer to theatre and is noted by theatre staff)

The second test of change commenced on 5 December 2016 focusing on  standardising the process of handover of intentional vaginal packs from delivery suite to observation area – introducing a sticker on the woman’s hand to denote this.

The following SPC charts demonstrate that a verbal handover is taking place and that a VP sticker is on the woman’s hand at transfer.

  • SPC chart 5 – noting the verbal handover of an intentional vaginal pack in situ
  • SPC chart 6 – noting the % of women transferred with an intentional vaginal pack in situ who had a “VP” sticker on their hand

A percentage of women have been interviewed about how they felt regarding having the sticker in place. 90% knew what the sticker was there for and felt reassured by its presence.

This safety improvement project has been presented at:

HEETV GP Fellows Event – Oxford, February 2016
IHI International Forum – London, April 2017
PSC National Conference – London, May 2017

Further information

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