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Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.
April 16, 2024
Dorset, UK: Health Services Safety Investigations Body; April 2024.
Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence. This report examines reasons for 31 incidents of retained surgical swabs reported in the United Kingdom’s National Health Service (NHS). Recommendations from the analysis focus on organizational work to limit the opportunities for swab retention that target system improvement rather those that lower impact changes directed toward staff behavior and training.
