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, the National Patient Safety Team identified issues with the safe clamping of the umbilical cord after a caesarean section.
It is routine practice to use Spencer Wells forceps to clamp the umbilical cord during caesarean section births. However, following an incident reported in the NRLS regarding Spencer Wells forceps cutting through an umbilical cord, we received feedback that a small number of maternity units now use a plastic cord clamp to clamp the umbilical cord during caesarean sections.
These cord clamps are not radiopaque and therefore would not be visible on x-ray if they were to be retained during the surgery.
We worked with the Royal College of Obstetricians and Gynaecologists (RCOG) to agree that if used, plastic cord clamps must be included in the instrument count both prior to and following the caesarean section; in accordance with the National Safety Standards for Invasive Procedures (NatSSIPs).
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.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. 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.