Abstract
Sir,
We would like to bring to the attention of all urology departments an incident which has occurred in our department, reported as a Never Event by our trust and which we suspect has the potential to occur elsewhere.
A female patient attended for a flexible cystoscopy in our department as part of our one stop haematuria clinic. No abnormalities were found. She was then reviewed a few weeks later complaining bitterly of discomfort ‘down below’. On examination a swab was found just within the introitus. We then discovered that a locum registrar was using a swab in selected female patients to aid introduction of the flexible cystoscope. Although swabs are on the cysto-scopy trolley, as the permanent members of the department only used them for cleansing the genitalia, swab counts hadn’t routinely been performed.
Discussion with other local Urology units suggested it is not normal practice to count any swabs on the cystoscopy trolley. It was also not normal practice to insert swabs during a cystoscopy procedure in this way, but a small number of colleagues were aware of this practice having been encountered elsewhere during their career.
We have now changed practice within our department and use a modified version of the WHO checklist for all procedures within our outpatient department that includes a swab check if a pack has been opened
We suggest other Urology units should review their practice where swabs are used in outpatient procedure clinics to ensure they have checks in place to avoid a retained swab such as occurred here, becoming a Never Event in other circumstances