Patient found "alleged retained swab"

A patient at the Royal Stoke University Hospital found an "alleged retained swab" after being discharged following a procedure.

The incident was one of two “never events” to be reported at University Hospitals of North Midlands (UHNM) NHS Trust, which runs Royal Stoke University Hospital and Stafford’s County Hospital, during the first three months of 2019, a report to this month’s trust board meeting said.

The other incident involved a unit of incorrect blood being used in a transfusion following a “massive haemorrhage”. But the patient made a full recovery and was later discharged, the report said.

Speaking at this month’s UHNM board meeting medical director John Oxtoby said: “There was a transfusion and an individual doing a check. There was no second check in that case.

“People will make mistakes from time to time. We have instigated a system where there is a second check and we don’t believe that will happen again.

“The swab is a more difficult one, because as we know this isn’t the first time we have had an issue with a swab. We had instigated what we believed to be a very rigorous approach with swabs, where they were counted in and counted out.

“On review of this patient there were the right number in and out so it is hard to see why there was a swab left. Nevertheless, this has happened.

“It is about enforcing this procedure. (The report) states ‘alleged’ – this is because we don’t actually know it is a swab. We have to assume it was.”

Further details about the incident, such as the location of the swab in the patient’s body and the type of procedure that took place, have not been disclosed to avoid potential identification of the patient.

In summer 2018 a guide wire was left in a critically ill patient’s body on the paediatric intensive care unit (PICU). An investigation took place following the incident and UHNM took a number of actions, including removing central venous catheter (CVC) sets containing two guide wires from the unit.


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