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Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

Dorset, UK: Health Services Safety Investigations Body; December 2023.

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January 17, 2024

Dorset, UK: Health Services Safety Investigations Body; December 2023.

Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence. This interim 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.

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Dorset, UK: Health Services Safety Investigations Body; December 2023.

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