Source · HSSIB Patient Safety Investigation
Detection of retained vaginal swabs and tampons following childbirth
HSSIB’s introductionRetained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common never event in the ‘retained foreign objects’ category.
Published 7 June 2021
Launched 11 July 2019
Published
HSIB Legacy
Medical devices
Checking
Indexed content
1 recommendation
1 observation
1 of 1 responded
Safety Recommendations
It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm.
AI-generated response summary NHS England confirms it already commissioned a first-stage independent evaluation of a proposed new swab/tampon design. Further evaluation, including comparison with other solutions and cost-benefit analysis, will be considered and conducted if manufacturing of final prototypes is feasible.
Response received 15 July 2020
The Patient Safety team at NHS England and NHS Improvement is pleased to confirm that in line with its stated intention it had already commissioned a first stage independent evaluation of a proposed new design for swabs and tampons used in healthcare maternity services. Whilst it would not be feasible to commission an evaluation of other solutions or technologies that have not yet been well developed, further independent evaluation to compare this proposed design with other available solutions, and to evaluate potential cost benefit and impact analyses will be considered, conducted and published, should final prototypes prove possible to manufacture to the required specification and standards, and before any staged roll-out is considered. Response received on 15 July 2020.
Safety Observations
It would be beneficial for trusts to review their planned handovers and for all staff groups to have adequate time in their shift to conduct handover tasks and participate in team briefings.
Practices at the end of tasks