Sentinel 3 Retained central line This was a complex insertion As the task is unable to be changed, guide wire following a required two central line packs to the intensive care unit has educated complex central line be used, resulting in the first wire all the staff who might be involved in insertion, requiring accidentally being left in place. any central venous line insertion to removal in radiology. maintain vigilance to ensure that the The standard technique for wire is removed particularly if two or – inserting central lines is the more kits are used. technique which is a ‘Seldinger’ well-established procedure in clinical practice used to introduce catheters, probes, electrodes, etc. into vessels. Serious 3 Retained surgical No policy in place within the Requirement that all medical officers Cardiology Dept now has radio swab following a setting by which the attending undertaking pacemaker implantation opaque gauze and all standard pacemaker insertion. doctor is required to advise the (or any other procedure involving an gauze has been removed. Swab found during scrub nurse/circulating nurse that open wound) to advise the scrub Swabs (and all other equipment another surgical an open wound is/has been nurse/circulating nurse of an used) are counted and procedure. with a gauze swab. intention, or the act of, placing a ‘packed’ documented as per the surgical gauze swab (or any other temporary No policy within the setting count policy. item) within the wound pocket. enabling and requiring an Patient X-rayed during procedure instrument, sharps and/or a swab Implement the Main Operating which would highlight any count to be undertaken when an Theatre Surgical Count Policy in this remaining gauze. open wound procedure is area. undertaken. All swab material to contain a The swabs used in the opaque marker. cardiology laboratory are not When a surgical site radio-opaque and therefore demonstrates signs of infection, cannot be identified upon and/or inflammation, and/or oedema, ultrasound or X-ray imaging. multi-view X-rays of the site are The potential for a retained performed for the purpose of product producing an excluding the possibility of retained inflammatory response does not equipment. have a mechanism for investigatory escalation.
Sentinel 3 Retained central line guide wire following a complex central line insertion, requiring removal in radiology. This was a complex insertion required two central line packs to be used, resulting in the first wire accidentally being left in place. The standard technique for inserting central lines is the ‘Seldinger’ technique which is a well-established procedure in clinical practice used to introduce catheters, probes, electrodes, etc. into vessels. As the task is unable to be changed, the intensive care unit has educated all the staff who might be involved in any central venous line insertion to maintain vigilance to ensure that the wire is removed – particularly if two or more kits are used. Serious 3 Retained surgical swab following a pacemaker insertion. Swab found during another surgical procedure. No policy in place within the setting by which the attending doctor is required to advise the scrub nurse/circulating nurse that an open wound is/has been ‘packed’ with a gauze swab. No policy within the setting enabling and requiring an instrument, sharps and/or a swab count to be undertaken when an open wound procedure is undertaken. The swabs used in the cardiology laboratory are not radio-opaque and therefore cannot be identified upon ultrasound or X-ray imaging. The potential for a retained product producing an inflammatory response does not have a mechanism for investigatory escalation. Requirement that all medical officers undertaking pacemaker implantation (or any other procedure involving an open wound) to advise the scrub nurse/circulating nurse of an intention, or the act of, placing a gauze swab (or any other temporary item) within the wound pocket. Implement the Main Operating Theatre Surgical Count Policy in this area. All swab material to contain a opaque marker. When a surgical site demonstrates signs of infection, and/or inflammation, and/or oedema, multi-view X-rays of the site are performed for the purpose of excluding the possibility of retained equipment. Cardiology Dept now has radio opaque gauze and all standard gauze has been removed. Swabs (and all other equipment used) are counted and documented as per the surgical count policy. Patient X-rayed during procedure which would highlight any remaining gauze.
SSE-cases-2010-11-FINALv1.docx