Reflecting on why surgical swabs are being left behind and exploring how this could be prevented

Abstract

Surgical swabs are routinely used by obstetricians and midwives to absorb blood during caesarean sections or perineal repairs following a vaginal birth. On rare occasions, a surgical swab can be left behind by mistake inside the patient's body. When an incident involving a retained swab occurs, this is declared a ‘never event’. Although a rare occurrence, a retained surgical swab is the source of high morbidity (infection, pain, secondary postpartum haemorrhage and psychological harm). It is also important to mention the financial burden and the legal implications affecting healthcare providers worldwide. Over the years, several strategies have been implemented in clinical practice to reduce such risk. However, none of these seem to provide a definitive answer. Having offered a brief overview of the evidence surrounding retained surgical swabs, this article presents an innovative approach based on creating a physical barrier by introducing an anchoring point linking the swabs together, making it physically impossible to leave one behind. At present, these modified swabs are undergoing development and testing.

‘The left behind syndrome’—surgical equipment errors in plastic surgery

“…Retained surgical swabs, instruments, needles and other pieces of paraphernalia used in surgery have implications from the surgical macro world to the micro one. Perhaps the commonest number of cases occur in the charged atmosphere of emergency obstetrics, 7 but even in ophthalmology, 8 where 'things tiny' may still be lost, the problem is widespread, even if supposedly rare.…”