Patient safety
The importance of effectively managing swabs
Following the publication of the HSSIB report, Tracey Pavier-Grant describes how an effective risk management strategy for the disposal of swabs can help prevent Never Events and provide surgical teams with peace of mind.
Every day thousands of operations are carried out using thousands upon thousands of swabs. As the number of swabs used in operating theatres continues to rise, due to the increased service demand, the need to effectively address the issue of retained items is more pertinent than ever. With NHS budgets under increasing pressure, healthcare providers can’t afford to not have a watertight policy in place. A duty of care to patients and healthcare colleagues is vital at every level and for every operation. The swabs used in each surgical procedure pose a potential threat not only to the patient but also to the staff handling them. The possible risks are many and varied. For patients, retained swabs can result in negative outcomes, including further surgery, prolonged hospital stays, distress and extended time off work. There is also the risk of infection and, ultimately, death. For healthcare staff, those acting as circulators in theatre are potentially at risk from cross infection due to unnecessary handling of dirty swabs. This could put them in danger of HIV, Hepatitis A, B and C, MRSA, Streptococcus and Staphylococcus, along with other bacterial infections. When a swab is unintentionally left inside a patient’s body, this type of patient safety event is referred to as a ‘Never Event’. A Never Event is an event NHS England considers to be wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at national level and have been implemented by healthcare providers (NHS Improvement 2018). NHS England’s provisional summary of Never Events, reported as occurring between 1 April 2022 and 31 March 2023, shows that there were 16 surgical swab and 32 virginal swab incidents during this period. The Health Services Safety Investigations
Body (HSSIB) investigation into retained swabs following invasive procedures explored the patient safety risk of swabs being unintentionally retained following an invasive procedure such as surgery. To explore the issue of retained swabs, the HSSIB investigation, completed under the NHS England (Healthcare
Safety Investigation Branch) Directions 2022, used a real patient safety incident, relating to the unintended retention of swabs, involving a patient who had undergone heart surgery. A family member of the patient had referred the case, following concern that two Never Events had happened in close succession, which resulted in the patient having to have two further invasive procedures. The investigation considered that the complexity and the workload associated with counting swabs, sharps and instruments, combined with carrying out other tasks, was high. Taking into account other variables, such as distractions and interruptions, competing tasks and time pressures, the study noted that it is evident the current process presents challenges to accurately accounting for all surgical items, including swabs. The investigation observed that once the swabs had been placed into the swab bag, it was difficult to see how many swabs the bag contained. Policy at the Trust, where the HSSIB
investigation was carried out, was that once
inside the bags swabs were not counted or verified again during or after the procedure unless a discrepancy in the count was detected. Staff reported that it would be time consuming to count every swab in the operating theatre each time for a full count, as they would have to open and go through all the bags. The accuracy of the final swab count depended on every intervening used swab removal count being correct. If an error in the count coincided with an unintended swab retention, this would not be identified during the swab count. The HSSIB noted that the low frequency
of patient safety incidents involving retained foreign objects, including swabs, indicates that the counting is largely successful. The HSSIB also observed that standards such as NatSSIPS (Centre for Perioperative Care, 2023) and ‘Standards and Recommendations for Safe Perioperative Practice’ (Association for Perioperative Practice, 2022) can help reduce the number of retained swab incidents. Counting items, however, is not a strong systemic barrier and retained swab events can
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