Ana Luisa Cavaco
National Guard Heath Affairs, KSA
Title: Quality improvement project- Reducing the Swab retention during vaginal delivery
Biography:
Ana Luisa Cavaco, Portuguese nationality, is a nurse and midwife with a passion in improving the health and wellbeing. Before coming to Saudi Arabia, was working in a Portuguese University Hospital for 25 years. Has been dedicating the last 22 years of her professional life to the obstetric area. Ultimately is leading a program that conduce the safety of the nursing and midwifery cares that allowed the mothers to deliver in a safe and serene environment. Enhance the function and operationalization of the unit, streamlining roles and functions. Promotes an open mind, motivates and inspires the team by couching and educating enabling harmless and effective cares. Is a strong voice for effective, holistic and dignified nursing and midwifery care for patients during intra-partum period. This improvement quality program, is a good example of the team success by engaging all stakeholders in innovative practices evidenced based.
Abstract:
In an universe of 8500 deliveries per year, between December of 2015 and March 2016, 4 incidents of swabs left in the vagina during the delivery were described on the safety reported system, with respective readmission of the patients for treatment. This repeated occurrence in a period of 4 months was an opportunity to reflect on clinical practices.
Swabs are used by obstetricians and midwives during vaginal delivery and perineal repair to clean and absorb blood. They can be difficult to identify once soaked in blood and are occasionally left inside the vagina by mistake. Retained vaginal swabs were more common than surgical swabs or any other category of foreign object. The impact of retained vaginal swabs can be severe. Women may experience serious physical and psychological complications including infection, secondary post-partum hemorrhage, sepsis, and depression, lack of bonding with their baby due to re-hospitalization and finally, loss of trust in the health organization with consequent discredit by the population. In addition they represent a significant problem in that they are very difficult to be defended in clinical negligence litigation, as they reflex the failure of clinician to comply with practice standard. The repercussions can harm the professionals as a ‘second victim’. Organizational consequences can be financial and reputational, as Never Events are considered to reflect quality and safety processes within an organization. Therefore, maternity service provider must put measures in place to manage this preventable clinical risk.