Hospital probe after swabs left in mums after birth

Calderdale and Huddersfield NHS Foundation Trust runs Calderdale Royal Hospital
Calderdale and Huddersfield NHS Foundation Trust runs Calderdale Royal Hospital
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Hospital bosses have launched an investigation after swabs were left inside three women after they gave birth, it has emerged.

Calderdale and Huddersfield NHS Foundation Trust has reported three ‘never events’ between September 2011 and January this year relating to “retained foreign objects” after natural births.

The blunders were reported at February’s Quality Assurance Board (QAB) meeting where members heard in each case there had been a failure to follow policy.

Bosses at the meeting warned staff should be reminded of their accountability and “poor practice will not be tolerated”.

The use of swabs is a common procedure in cases where there has been tearing of the skin after a natural birth.

A swab can be a cotton wool bud or a piece of gauze used to clean a wound or to apply pressure - but in these three cases they had been left in the women.

Never events are incidents which should not have taken place if proper safety measures are implemented.

A report from the QAB meeting said: “Following the three never events within the CWF (children, women and families) division, the Quality Assurance Board have not been assured that good practice is primary and that policies are being adhered to.”

Medical director David Wise said this week: “We have individually investigated each of these events and have identified learning from them.

“To provide extra assurance we are now looking at the events together to ensure that we have captured all the learning that is to be had.”

At the same QAB meeting, the board heard the trust had reported 179 incidents relating to medication errors between September to December 2012.

Four of these incidents were graded as red/near miss, 12 yellow and 163 green.

Mike Culshaw, clinical director of pharmacy at the trust, told the board that nationally, administration errors account for five per cent of doses, which equates to 350 medication errors per day in each hospital.

Medication errors can occur in prescribing, dispensing or administration.

The meeting heard investigations at the trust are focusing on how to reduce missed doses and medication errors occurring when a patient is discharged, which can result in readmission.

Mr Wise and deputy director of nursing Jackie Murphy are investigating a snapshot of medication errors, reported over a one-month period, to see what lessons can be learned.

Mr Culshaw said: “Medication errors cover a wide range of incidents, the majority of which result in no harm to patients.
“Within the trust we encourage the reporting of any medication error so we can ensure improvements are made to prevent any future incidents.”