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Tracking subsequent removal of intentionally retained swabs | Signal

Reference number
Issue date29 September 2011

This Signal relates to the risk of intentionally retained swabs planned for later removal not being subsequently removed.


A sample incident reads:


“Patient involved in road traffic accident sustaining major abdominal trauma. Existing multiple co-morbidities. Admitted via the ED and underwent emergency laparotomy by surgeon 1. Cardiac arrest at induction of anaesthesia and severe intra-abdominal bleeding circa 5000ml. 2 packs placed intra abdominally for bleeding and external ‘dressing’. Further laparotomy by surgeon 2 next day and 2 ‘packs’ removed. Four days later a CT scan revealed swab in situ. Following day emergency laparotomy by surgeon 1 found one retained intra abdominal pack and retrieved it.”


In surgical and gynaecological procedures packs can intentionally be left in the cavity or wound on a short term basis, as a dressing or to minimise bleeding.


A search of all incidents reported to the National Reporting and Learning System (NRLS) from inception to April 2009 identified 19 reports of issues relating to swabs/packs that had intentionally been left in surgical wounds.


The key issues identified include:

·         Poor documentation – retained swabs not recorded in the patients notes;

·         swabs/packs not removed when planned;

·         swabs/packs/ribbon gauze cut; and

·         non X-ray detectable gauze swabs used.


The Standards and Recommendation for Safe Perioperative Practice (2011) from the The Association for Perioperative Practice (AfPP) state:


“Items which are to be retained in the patient (for example packing gauze, drain tubes, catheters) must be recorded in the intraoperative record theatre register/patient’s notes. Their removal must also be recorded, including the time, date, name and designation of the practitioner removing the item.”  


We would like to hear from you – please contact us with your initiatives to reduce risks in these areas. We can share them with appropriate forums for example the Clinical Board for Surgical Safety.


Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.