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Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.

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January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

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Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.