Never Events - the ongoing problem of the retained vaginal sponge/swab.

Abstract

NHS England recently published their annual Never Events data summary (a Never Event is defined as ‘a serious incident that is wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’). Between April and March 2014/15 there were 306 Never Events. One-third of these were ‘retention of a foreign object in a patient after a surgical/invasive procedure’, a definition that includes interventions related to vaginal birth. Closer analysis of the data reveals that there were 36 cases of retained vaginal sponges/swabs. This amounts to over one-third of all retained foreign objects, and accounts for nearly 12% of all Never Events. The retained vaginal sponge/swab after vaginal birth is a universal problem. A study carried out in the USA found that vaginal sponges/swabs accounted for 22% of retained foreign bodies, and that sponge/swab counts had been omitted after all 11 vaginal births (Gawande et al. N Engl J Med 2003;348:229–35). In 2010, the UK National Patient Safety Agency published a Rapid Response Report mandating NHS organisations to implement a seven-point action plan requiring formalised swab counting procedures after all vaginal births to minimise the risk of retained vaginal sponges/swabs (Table 1). The introduction of such counts has been shown to be acceptable to healthcare professionals in the USA (Lutgendorf et al. Mil Med 2011;176:702–4; Chagolla et al. MCN Am J Matern Child Nurs 2011;36:312–17). Repair of perineal trauma after vaginal birth presents unique challenges. Repairs are often carried out in the delivery room by a single professional with limited maternal analgesia and poor lighting. Once soaked in blood, vaginal sponges/swabs are often difficult to identify. Repairs are commonly carried out by trainees who may not grasp the importance of fastidious sponge/swab counts. The presence of family members and a new baby are further distractions. A retained vaginal sponge/swab can harm the patient, healthcare professionals and the organisation. The woman may experience discharge, infection, secondary haemorrhage and/or psychological harm. The repercussions can harm the professionals as a ‘second victim’. Organisational consequences can be financial and reputational, as Never Events are considered to reflect quality and safety processes within an organisation. Although the introduction of swab counts has been shown to reduce the incidence of retained surgical sponges/swabs, the system is not infallible. Sponges/swabs can be retained even when a documented count has been performed (Gawande et al. N Engl J Med 2003;348:229–35) so total reliance on swab counts is insufficient. Technology may provide an answer. A large study from the Mayo Clinic reported that the introduction of a data-matrix bar-coded counting system totally eliminated retained surgical sponges/swabs, providing an acceptable, reliable and cost-effective solution (Cima et al. Jt Comm J Qual Patient Saf 2011;37:51–8). Addressing the challenge of the retained vaginal sponge/swab would help to achieve the NHS's aspiration of zero Never Events. Until perineal suturing is afforded the same status as other surgical procedures, the problem is likely to remain. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.