Patient safety
incident investigations tend not to explore the various factors in depth and tend to focus on the actions of staff. In an interim report published in December, HSSIB had analysed 31 serious incident reports focused on retained swab events, and drew out common characteristics in those incidents, ranging from the type and duration of surgery to the responsibility for swab counts and competing pressures. The report emphasises that 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. Therefore, recommendations made in serious incident reports are often focused on further training or reminding staff to follow procedure without fully understanding why the process might not be effective. HSSIB’s report refers to how other safety
critical industries manage risk, where they assess whether a risk has been reduced to ‘as low as reasonably practicable’ (ALARP). It involves balancing the risk with other safety priorities, costs, benefits, productivity, and efficiency. HSSIB have highlighted that the concept of ALARP could help with understanding and planning for risk, as well as assessing possible mitigations like tools and technology and what their impact could be. The report concluded with three safety
recommendations – one is focused on reviewing and amending the process and standards for the reconciliation of swabs, using human factors expertise and user-centred design. The second recommendation is focused on developing a framework to assess whether healthcare risks, such as retained swabs, are acceptable,
tolerable and have been reduced to as low as reasonably practicable. The third is to conduct research to assess the priority and feasibility of implementing technology that could support reducing the risk of retained swabs. The report also makes the following safety
observations: l Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.
l The NHS can improve patient safety by ensuring procurement decisions about swabs are made on a risk-informed basis
The key safety findings
1. 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.
2. 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.
3. Other safety-critical industries assess and control risks to be ‘as low as reasonably practicable’ (ALARP), where there is not an expectation to eliminate all risk. These risk management principles have not been applied to the risk of swabs being unintentionally retained.
4. There is no accountability framework, and it is unclear who owns the risk for retained swabs and reducing the risk for retained swab events to as low as reasonably practicable.
5. 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.
6. Staff and national organisations had varying views on the roles and responsibilities for swab reconciliation; limitations in training were identified.
7. The investigation was told by various national organisations that there is a concern about removing Never Events from the NHS’s
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framework and how determining risk appetite (where it is accepted a level of harm will occur) will be perceived by the wider public.
8. The design of swabs does not help staff to locate, identify, or track swabs during the reconciliation process.
9. 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.
10. The technology and tools have not been formally considered using risk management principles in terms of reducing the risk to as low as reasonably practicable, or how the technology could reduce other patient safety concerns while also supporting productivity and efficiency in healthcare.
that incorporates evaluation trials and user-centred design processes in the design, manufacture and testing of products.
l 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.
l A user-centred evaluation of non- technical tools to aid the swab count can improve patient safety by helping national
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