Implementation of the Swabsafe™ management system at the The Princess Grace Hospital following a never event.
It happened on a Saturday, 19.30pm, in April 2012. I was the theatre coordinator. We had a 'never event' of a retained swab in a breast wound.
The following week, I changed practice following audits for four weeks in eight theatres. We never looked back. Attached is the poster presented in November 2016 at the Patient First Excel conference.
Until recently no one ever asked me how I felt. I knew what to do. But I felt for the surgeon. As theatre scrub practitioners we complete counts and inform the surgeon. He acknowledges the count. If later on a swab is retained, it's the surgeon who has to inform the patient and remove it.
By using a system especially designed for counting swabs (see video below), we can stop never events of retained swabs and maintain safety for the patient, the consultants, perioperative staff and also the hospital.
We have the technology – let's use it!
Kathy showcasing the Swabsafe Management poster at the Patient First Event, Excel London.