Case study: Retained surgical instrumentation and complex procedures involving multiple teams and equipment (15 August 2023)

Summary

This article describes how NHS England's National Patient Safety Team identified an issue relating to retained surgical instrumentation during complex procedures. A specific review of Never Event data revealed that some reports describing unintentionally retained instruments involved complex procedures where more than one surgical team was involved with multiple instrument trays, making the counting/checking process more difficult. There was no specific national guidance for this issue, so NHS England liaised with the Centre for Peri Operative Care (CPOC) as part of their review of the National Safety Standards for Invasive Procedures (NatSSIPs 2). This led to the addition of a caution moment in situations where there are multiple trays, teams and handovers, in the revised standard ‘Reconciliation of Items in the Prevention of Retained Foreign Objects’.