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Author Ahmed ElGharably, Kiran Desai, Aaron Vance, Jon Lester, Emma Bonfiglio, Colin Rigby, Andrew Forrester, Prof Peter Ogrodnik, Jeffrey Faint, Prof Tom Clutton-Brock, Aditi Desai |
| Abstract Retained vaginal swabs are a well-recognised and recurrent patient safety ‘never event’ with the potential to cause significant morbidity. Surgical swabs and surgical tampons, which are considered a type of surgical swab, are the single largest retained item. There have been 340 incidents of retained vaginal swabs reported in England (2012-2022) and underreporting of these incidents is known. The current practice of manual counting is prone to human error and demonstrates a lack of efficacy in dealing with this issue. A simple, cost-effective device was developed collaboratively based on human factors/ ergonomics principles. This is designed to help users focus on the largest problem space, functioning as a physical checklist and memory aid for accurate counting. The team adopted a systems thinking approach to develop the innovation, progressing through steps such as hierarchical task analysis and human factors systems analysis through the SEIPS framework, AcciMap, barrier analysis and user-centred iterative design. The near-manufacture prototype was user-tested in simulation, and results indicate that the device has the potential to facilitate accurate counts in a time-efficient manner. We acknowledge that there will be a need for training, and culture change for the adoption of design solutions in the current workflow. It is known that around 94% of units have electronic records, and software development in order to integrate the deviceaided count into electronic medical records with a computer vision app is ongoing. With integration into existing software, the system will not complete the birth episode unless the count tallies. With some additional resources, our vision is to develop and introduce a strong systemic barrier to prevent the problem. Initially, it may be practical to introduce only the device, which acts as a physical checklist and increases system resilience. System engineering tools such as the use of checklists are well-accepted models within patient safety science. However, the role of design which complements human behaviour in achieving system improvement is relatively unknown to healthcare professionals and we intended to explore this. |
