The recurring problem of retained swabs and instruments

Patient safety is one of the most pressing challenges in health care. The promotion of safety requires that all those involved in healthcare realise that the potential for errors exists, and that teamwork and communication are essential for preventing errors. Incidents compromising patient safety, such as unintended retention of swabs or instruments, are regarded as ‘never events’. These incidents are considered ‘unacceptable and eminently preventable’, as pointed out by the Department of Health ‘never events list’ 2012/2013. One estimate says that one case of a retained item occurs at least once a year in a major hospital where 8000 to 18,000 major cases are carried out each year. All healthcare organisations should take appropriate measures to prevent retention of foreign bodies by consistent application of reliable and standardised processes of care. In this review, we explore the risks and complications associated with retained swabs and instruments, and different ways to prevent such risks to patients.