Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency

Lamont, Tara; Dougall, Anita; Johnson, Sara K.; Mathew, Dinah; Scarpello, J. H. B.; Morris, Edward

doi:10.1136/bmj.c3679

Cited by 7 publications

(3 citation statements)

References 2 publications

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“…10 A recent safety alert in the British Medical Journal now has released recommendations for dual counts at the time of all perineal suturing. 11 In this respect, the simple measure of introducing a proforma has had a statistically significant impact on this basic standard of care. In clinical terms and with respect to clinical risk management teams we should be aiming for count rates of one hundred percent.…”

Section: Discussionmentioning

confidence: 99%

Clinical risk management of obstetric anal sphincter injury

Burke¹,

Corcoran²,

Ryan³

et al. 2012

Clinical Risk

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Perineal injury sustained during childbirth, and more particularly third and fourth degree tears, can have substantial effects on future continence, sexual function and the choice of method of childbirth in the future. The aim of our audit was to see if the use of clinical risk management methods could help improve documentation and clincial outcomes for women who sustained an obstetric anal sphincter injury. A proforma for the management of obstetric anal sphincter injury was introduced to the labour ward. We found that after the introduction of the proforma documentation improved significantly for classification of the type of injury (P , .01), counts of swabs, instuments and sharps (P , .01) and future pregnancy information (P , .05). This audit demonstrates how simple clinical risk managment strategies can help ensure the best standards of care are implemented.

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Section: Discussionmentioning

confidence: 99%

Clinical risk management of obstetric anal sphincter injury

Burke¹,

Corcoran²,

Ryan³

et al. 2012

Clinical Risk

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“…There are very few interventions reported in the literature to reduce retained swabs specifically in maternity settings, although maternity-specific guidelines do exist [13]. The use of a spongecount sheet, documentation of the accuracy of sponge counts and communication training has been shown to improve compliance with sponge counting procedures in maternity [14].…”

Section: Introductionmentioning

confidence: 99%

Improving communication at handover and transfer reduces retained swabs in maternity services

Lean

Page

Vincent

2018

European Journal of Obstetrics & Gynecology and Reproductiv

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“…Retention of vaginal packing, whether gossypiboma or intentionally placed gauze, is associated with serious psychological and physical complications including depression, pain, infection, tissue necrosis, and even death [2][3][4]. The Joint Commission classifies retained vaginal packing as a reviewable sentinel event and is reportable as a breach in quality and patient safety [5].…”

Section: Introductionmentioning

confidence: 99%

Preventing Retention of Vaginal Packing in Obstetrics: Implementation of a Protocol to Improve Patient Safety

2018

JGRM

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Background: Retained vaginal packing can be associated with serious psychological and physical complications. The purpose of this study was to enhance patient safety by implementing an obstetrical vaginal packing protocol and to evaluate its efficacy. The study occurred in a tertiary maternity center with roughly 6,000 deliveries a year. Methods: A vaginal packing protocol was instituted. The protocol added a “vaginal packing” button to the electronic health record that subsequently prompted a notification to remove and document removal of the packing. A retrospective chart review of compliance with the protocol was performed on all deliveries that occurred during a 1-year period after implementation. Results: Of the 6,118 deliveries, 92% (5625/6117) completed the vaginal packing section of the delivery summary. Vaginal packing was placed in 1% (63/5625) of the deliveries in which the delivery summary was completed. A note documenting removal of the packing occurred in 73% (46/63) of the deliveries. There were no cases of retained vaginal packing. Conclusions: This is an effective and sustainable protocol to prevent retention of vaginal packing. This process could be adopted in the gynecologic setting and among many hospitals.

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Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency

Cited by 7 publications

References 2 publications

Clinical risk management of obstetric anal sphincter injury

Clinical risk management of obstetric anal sphincter injury

Improving communication at handover and transfer reduces retained swabs in maternity services

Preventing Retention of Vaginal Packing in Obstetrics: Implementation of a Protocol to Improve Patient Safety

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