Patient safety
Risk of surgical swabs being left inside patients
The Health Services Safety Investigations Body (HSSIB) investigated the risk of unintentional ‘retained’ swabs after invasive procedures, having examined the case of a patient who had two swabs left in her chest, following serious heart surgery.
When operating on a patient, a surgeon may put swabs 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. A report by HSSIB examined what influences the reliability of the swab count, and how achievable the overall reconciliation process is. Retained swabs are classed as Never Events. However, data shows that there have been between 11 and 23 retained swab incidents a year since 2015. HSSIB have suggested in their report that while the counting of swabs may be ‘largely successful’ in preventing these types of incidents, it does not provide a ‘strong systemic barrier’ to error. This was shown in the case set out in the
report. Helen underwent a procedure to treat coronary artery disease. It took approximately five hours to complete and involved opening her chest to expose her heart. Following the procedure, a chest X-ray identified that a swab had been left inside her chest and the wound had to be opened again so it could be removed. After this procedure, another chest X-ray showed a second swab remained in her chest and she returned to the operating theatre, her third time in total.
Helen’s case and HSSIB’s wider investigation,
which involved interviews and a focus group with NHS operating theatre staff and observations at an NHS Trust, showed there
are many complex factors which influence the reliability of a swab count and achievability of the overall reconciliation process. This includes: l The design of swabs (for example, the swab becomes difficult to see once inside a patient).
While the number of retained swabs appear relatively low, they continue to occur and there has been up to 23 patients in a year experiencing an incident and the negative patient outcomes that can come with it – from distress and trauma, the risk of infection, to further surgery and prolonged hospital stays. Saskia Fursland, Senior Safety Investigator, HSSIB.
l The environment (for example, the theatre environment can be noisy and busy), organisational factors.
l Pressures (for example, waiting list pressures means there is an emphasis on increasing throughput in theatres, adding time pressures on staff).
l How the task interacts with others that are going on at the same time (for example, staff are counting potentially hundreds of other surgical items, while also preparing the equipment the surgeon needs).
They highlight that 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. HSSIB also identified that Trust serious
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