A quality improvement project undertaken in partnership with Oxford AHSN and a maternity unit in the Oxford AHSN region.

The project started in September 2015 when a review of previous near misses and never events demonstrated a common theme – the lack of communication at handover/transfer. Interventions were introduced to improve communication at handover from the delivery suite to theatre and from theatre to the high dependency unit. Process data was collected to monitor compliance.

Results: For women transferred from delivery suite to theatre, verbal handover significantly increased from 28.8% to 75.6% (p<0.0001), and written handover significantly increased from 4.4% to 62.9% (p<0.0001).

Following a baseline of four near misses in two months, there has been only one near miss in the 15 months since the interventions were implemented, (33.3% vs. 1.1%, p<0.0001). There have been no retained swab incidents since the project commenced. This project demonstrates that simple interventions to improve communication at handover and transfer can reduce the incidence of retained vaginal swabs and near misses.

A write up of the project has been co-authored with Charles Vincent and published by the European Journal of Obstetrics and Gynaecology and Reproductive Medicine and is now available via open access using the following link bit.ly/2zsZrt6 .