Through its core work to review recorded patient safety events, the National Patient Safety Team identified an issue relating to retained surgical instrumentation during complex procedures.
A specific review of Never Event data revealed that some reports describing unintentionally retained instruments involved complex procedures where more than one surgical team was involved with multiple instrument trays, making the counting/checking process more difficult. In the absence of specific national guidance for this issue we liaised with the Centre for Peri Operative Care (CPOC) as part of their review of the National Safety Standards for Invasive Procedures (NatSSIPs 2). The revised standard ‘Reconciliation of Items in the Prevention of Retained Foreign Objects’ now includes a caution moment in situations where there are multiple trays, teams and handovers.
The inclusion of this new recommendation in these national standards, which are used across the NHS, will ensure a prompt step is incorporated in this environment to reconcile all equipment and disposable items that are at risk of being retained.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.