Perioperative practice
l Bad systems l Not checking properly l Tired l Burnout l Complacency l Lack of concentration l Lack of respect for nurses l Poor organisation l Noise
He highlighted that communication is reported as the highest coded causative effect, along with cognitive demand, distraction, confirmation bias, complacency and over confidence. In particular, prone positioning of the patient in surgery can cause potential risks with wrong site surgery, he pointed out – when the patient is ‘flipped over’, the left and right side can become confused. Gastrointestinal surgery and thoracic surgery
have the highest rates of never events, while there is a lower rate in neuro, genito-urinary and orthopaedics. Some of the reasons suggested for this is the nature of the cavities involved with these specialties – highlighting the importance of counting swabs at the right time. The length of operation is also a factor – the highest rates are for procedures <1 hour or >4 hour. In procedures less than an hour in length, there is a quick turnover, and this can lead to rushing. In procedures of more than four hours,
37 31 15
there is a greater risk of cognitive overload and tiredness. Teaching hospitals and the number of surgeons in the theatre also has an influence on rates. “If there are a lot of surgeons, the risk of
leaving a swab behind goes up. It is an issue of ‘too many cooks’,” he commented. “In teaching hospitals, you find there is more conversation between the consultants and the juniors, since they are teaching, so they become less aware of where the swabs actually are.” He highlighted the importance of following
checklists, standard operating procedures and swabs policies. “You should all have a reconciliation policy and follow it in the same order. Always count your instruments, swabs, needles, etc, in the same order because you are less likely to miss one of them and forget them,” he asserted. Paul Wheeler referred to a study which found
that, in relation to incidents of retained foreign objects (mainly swabs), only 77% of recorded that a swab check had been performed. In addition, 70%-80% of counts were correct – highlighting an opportunity for improvement. Distraction is a particular issue when counting swabs and instruments. “What is also worrying, is the fact that between 70% and 88% were recorded as ‘correct’, when in fact the swab was inside the patient. All of these people
believed that they had counted correctly, and they had accounted for all of their items, when they hadn’t. This relates to ‘confirmation bias’. You see what you believe you see; you don’t see what your eyes actually see,” he commented. He referred to the human factors training video known as the ‘Monkey Business illusion’ (
https://youtu.be/IGQmdoK_ZfY). In this scenario, the viewer becomes so distracted by counting ball passes, that they fail to see a gorilla walking between the players. This demonstrates the need to take a step
back and ensure you are counting what is actually in front of you, not what your head is telling you. “It goes back to critical thinking. Always think you might be wrong, and you are less likely to be wrong. We are not infallible and that is the key to remember,” he advised. “There is also guidance that when you change a team that you should have a swab count. When the team changes, the gold standard is that the people who have counted at the beginning of the case are the ones who should count the end of the case. If you have to change the team because it’s long procedure or there is a shift change, there must be a full count in between, to iron out those errors.” Good leadership is also key, along with a supportive work culture and staff engagement. Evaluating the working culture experienced by delegates, he surveyed the audience as to whether they would find it easy to speak up at their Trust. “It’s quite a nice number… There’s probably
40% of hands down and that’s such a shame. Speaking up is so important. It is really difficult to be that one, to be that whistleblower, but why are you doing it? Because there’s a patient here…that’s really important,” he asserted. Paul Wheeler highlighted the value of
Wrong site surgery Retained foreign object Wrong implant/prosthesis What never events have you been involved in? 63 11 3 Unsafe Poor Neutral How do you rate the safety culture within your Trust? 20
www.clinicalservicesjournal.com I October 2025 Good 15 3 Excellent
reporting to Datix – a risk management information system used by many hospitals. “A lot of you probably think, nothing ever happens with a Datix, as you never hear anything back… But there is somebody watching every single Datix that goes in,” he commented. He pointed out how quickly the exec board got in touch wanting to have answers, in one scenario. They turned up just 10 minutes after submitting a Datix, following the death of a patient. He went on to ask the delegates to rate the safety culture in their Trust using the Mentimeter App. The majority (63) rated it as ‘good’, three rated it as ‘excellent’, 15 rated it ‘neutral’, 11 said it was ‘poor’, while three described it as ‘unsafe’. The reasons for the positive responses included: l Dedicated staff l We are open about things that go wrong l We follow protocols
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