HSSIB Interim report: Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (7 December 2023)

Summary

This investigation explores the patient safety risk of unintended retention of surgical swabs after surgery.

Surgical swabs are sterile pieces of gauze which are used to absorb bodily fluids, such as blood, during a surgical procedure.

The investigation will:

• explore the factors associated with unintentional retained surgical swab events
• identify alternative safety controls to reduce the likelihood of foreign objects being unintentionally retained.

The interim report analyses the findings of 31 NHS trust serious incident reports.

Content

Reference event

The reference event involves a patient who had undergone a triple coronary artery bypass graft surgery (heart surgery).

Following their surgery, a chest X-ray identified that a surgical swab had been retained. The patient returned to theatre and the surgical swab was removed. A subsequent chest X-ray identified that a further surgical swab remained in situ, in the same location within the chest. The patient returned to theatre and the second surgical swab was removed.

Safety recommendations

HSSIB recommends that NHS England incorporates the findings of this interim report into its review of the Never Events policy, with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events.

Safety observation

• Organisations can improve patient safety by using consistent terminology in national and local guidance when describing the responsibility for the reconciliation of items used in surgery and invasive areas, including swabs.
• Local-level observation: Healthcare providers can improve patient safety by using the findings of this report to consider potential challenges in their own systems and processes for unintentionally retained swabs following invasive procedures. This can help organisations to understand what people focused and system focused barriers may be implemented to help further mitigate against retained swab events.