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Retained instrument post-operation

*Changes to the core list for 2010/11 are marked in bold



One or more instruments or swabs, or a throat pack, are unintentionally retained following an operative procedure, and an operation or other invasive procedure is needed to remove this, and/or there are complications to the patient arising from its continued presence. This Never Event does not include interventional radiology or cardiology procedures, and the definition of instrument does not include guidewires, screws, or other similar material. It does not include retained swabs after non-operative vaginal delivery.**


** This excludes retained swabs after vaginal delivery for 2010/11: ‘non-operative’ relates to the delivery being vaginal, not caesarean. As with all Never Events, final decision-making around individual events and local definitions is for commissioners to discuss with providers.

Main care setting

Organisations that provide major, minor and/or day case surgery.

Preventative guidance

Unintentionally retained instruments are a potential cause of complications and repeat surgery. Most providers will have developed their own local policies based on available advice, including the following in the UK: