HSSIB investigation report: Retained swabs following invasive procedures (16 April 2024)

Summary

When operating on a patient, a surgeon may put swabs (pieces of gauze that come in a range of types, shapes and sizes) into the patient’s body to absorb bodily fluids such as blood. The operating theatre team count the swabs in and out, using a process known as reconciliation, to ensure all swabs are accounted for at the end of the operation. However, sometimes a swab can be unintentionally retained (left inside a patient’s body).

This type of patient safety incident is known as a ‘Never Event’ – that is, an event that NHS England considers to be wholly preventable. This report is intended for healthcare organisations, policymakers, and the public to help improve patient safety in relation to retained swabs following invasive procedures.

Content

This report includes the following findings:

• A range of complex and interrelated system (tools, technology, organisation, task, environment, and people) factors routinely influence the reliability of the swab count and the achievability of the overall reconciliation process.
• The reconciliation process has not been formally analysed or designed using human factors expertise (where the interactions between people and other elements of the system in which they work are explored) or any other process design expertise.
• Blame can be inappropriately placed on scrub practitioners and/or the surgeon when an item goes missing, rather than the reconciliation process being seen as a team activity and one that can be influenced by a wide range of interrelating factors.
• The design of swabs does not help staff to locate, identify, or track swabs during the reconciliation process.
• There are technologies and tools that could be used to improve the accuracy of the swab count; however, these have not been embedded into UK healthcare.

Safety recommendations

The report makes the following recommendations:

• The Centre for Perioperative Care and Association for Perioperative Practice work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors expertise and user-centred design principles, to reduce the risk of retained swabs to as low as reasonably practicable. Any changes to either organisation’s processes should consider potential unintended consequences and the influence on other safety-critical tasks and include consideration of professional roles and responsibilities in relation to swab reconciliation.
• NHS England develops a framework to assess whether risks, such as retained swabs, are acceptable, tolerable and have been reduced to as low as reasonably practicable. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance.
• The National Institute for Health and Care Research assesses the priority and feasibility of commissioning research to review the viability of implementing technology that could support reducing the risk of retained swabs. The review should balance patient safety, costs, benefits, design, implementation, and the various ways in which the technology could be used to reduce other patient safety concerns to as low as reasonably practicable.

Safety observations

The report makes the following observations:

• Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.
• The NHS can improve patient safety by ensuring procurement decisions about swabs are made on a risk-informed basis that incorporates evaluation trials and user-centred design processes in the design, manufacture and testing of products.
• Multidisciplinary team training can improve patient safety by increasing the understanding of team roles, responsibilities, teamwork, the interrelationships between the work system and people and ultimately improve the care of patients undergoing an invasive procedure.
• A user-centred evaluation of non-technical tools to aid the swab count can improve patient safety by helping national organisations and trusts assess whether their risk of retained swabs is as low as reasonably practicable.

Further reading on the hub:

• Swab safe management to prevent retained swabs
• Oxford University surgical lectures: Retained swabs