Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports

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.

Organisations can improve patient safety by using consistent terminology in national and local guidance when describing the responsibility for the reconciliation of items used in surgery and invasive areas, including swabs. How is information about swabs communicated? Challenges in communication between operating theatre team members were frequently highlighted in the serious incident reports. For example, there were incidents where: Surgeons had not informed the scrub practitioner when the surgical swab had been inserted into the patient. However, this was often due to other safety critical and/or role-related tasks being conducted at the time the surgical swab was inserted, such as controlling a bleed. Swabs that had been inserted into the patient were not always documented on the count board (a whiteboard within the theatre where the swab count was documented). Reports described this happening when information had either not been verbalised (spoken out loud), had not been heard, had not been noticed by the rest of the operating theatre team or where there was no dedicated space on the count board to record the information. Additional challenges reported included: communication about the count being misunderstood among the operating theatre team communication not being acknowledged or being ignored the confidence of staff to speak up high noise levels in the operating theatre from the laminar flow (a ventilation system used in operating theatres) personal protective equipment, such as masks, visors and/or a surgical hood, making it difficult to see or hear communication. The communication challenges meant that staff could have different perceptions of what was happening, which then influenced their actions. It was not always clear in the serious incident reports what contributed to some of the communication challenges. Some of the reports mentioned issues in the culture where some team members may not feel comfortable speaking up. Others reported that the nursing staff did not feel listened to. ‘… the theatre staff stated that they felt ignored by the surgical operators when raising their concerns.’ It was evident from the thematic analysis that there can be issues relating to junior staff challenging more senior staff. ‘… more junior theatre staff are not fully confident in proactively speaking out against unsafe or potentially unsafe practice …’ ‘The circulating nurse knew this was not correct procedure, however she was under her preceptorship process [a structured start for newly qualified practitioners] and the scrub nurse was her supervisor.’ Some trusts had implemented innovations to enhance the culture of patient safety and the ability of staff to speak up. These innovations included ‘pause for gauze’, or a ‘HALT’ moment. The aim of these innovations was to allow staff to speak up, using terminology that can be understood by the whole operating theatre team, to allow time and minimise disruptions while the swab count was being conducted. A ‘STOP I have a concern’ phrase was also used to empower staff to speak up. However, it was evident in the serious incident reports that these new practices were not always being used or were not always successful in their aim. It was unclear from the serious incident reports why this was the case as the investigations only reported what staff did not do, rather than considering the influence of context and system factors. ‘The scrub nurse repeated this several times asking for everything to stop whilst the count was performed again and an attempt made to locate the swab. No verbal recognition of the information given to the surgical team was made.’ ‘… there was no “pause for the gauze”.’ ‘… there was a missed opportunity for staff to call a HALT moment.’ The current swab reconciliation process relies on effective communication. However, the thematic analysis showed there are many ways in which communication can break down in the operating theatre environment. How visible is a swab? The position of a swab in a patient’s body meant that it may not always be in direct line of sight. In other instances, the scrub practitioner could not see where swabs were because the surgeon was standing in a position that blocked their view. Staff also commented that smaller swabs were more difficult to see. Although not highlighted in the thematic analysis, the investigation is aware of another factor that can limit the visibility of swabs: when they absorb blood, the visual contrast with the surrounding tissue is reduced. This was identified as part of an investigation into the ‘ Detection of retained vaginal swabs and tampons following childbirth ’ (Healthcare Safety Investigation Branch, 2019). NatSSIPs (NHS England, 2015) states that ‘all swabs used for invasive procedures should contain radio opaque markers’ (markers that show up on an X-ray) as they can be used to detect retained swabs. NatSSIPs2 continues to endorse the use of radio opaque markers (Centre for Perioperative Care, 2023). The radio opaque strip within a swab appears as lines on an X-ray (see figure 2). There can be many other similar looking lines depicting other items or features on an X-ray image. Therefore, the retained swab may not stand out to the person reviewing the X-ray. In addition, when attention is focused on one object or task, it can be at the expense of noticing and attending to other available information (Mack, 2003). This means that when an X-ray is performed for reasons other than detecting a retained swab, such as a suspected collapsed lung, the person reviewing it will be focused on looking for signs of a collapsed lung and may therefore miss something that indicates a swab. This type of occurrence was noted in another investigation into the placement of nasogastric tubes ( Healthcare Safety Investigation Branch, 2020 ), where a misplaced nasogastric tube was not initially detected. Figure 2 Chest X-ray showing one retained swab Who is in the team? The analysis of the serious incident reports identified that changes to the team during a procedure or that different teams were conducting the swab count were considered as contributory factors. When there is a change of team, NatSSIPs (NHS England, 2015) suggested that a swabs, sharps and instrument count should be conducted between the outgoing and on-coming scrub practitioners. On a few occasions, this count had not occurred. Reasons for the counts not being conducted included tension in working relationships between operating theatre staff, or seeing other colleagues conducting a count and feeling that their assistance was not required. Reports discussed the risk caused by shift changes during invasive procedures and the impact this has on the continuity of staff and, in turn, the impact on tasks such as swab counting. NatSSIPs 2 (Centre for Perioperative Care, 2023) has made it more explicit that a count should be performed if there is a changeover of either the scrub practitioner or circulating practitioner. In addition, the reports commented on challenges created because of limited numbers of staff being available on the day. Limited staffing meant the team skill mix for the day was not optimal, that there was not a scrub practitioner available for the count, or that staff were required to work a longer day to ensure there were enough staff to cover a procedure. When did the swab count occur? In some of the reports reviewed, the skin had been closed before the final swab count had been completed. The reports offer explanations for this, including a lack of clear communication between the surgical team and the scrub team, or where the surgeon perceived the final count was correct as they had been handed instruments for closure. ‘Sign Out’ (a checklist performed at the end of an invasive procedure) was also seen to be completed before the count was finalised. Reasons given for this included: to complete the case efficiently to enable the operating theatre to be made ready for the next patient the scrub practitioner and circulating nurse perceiving that they knew where all the swabs were and thought the count would (when conducted) be correct. In some cases swabs were still being used while the count was being conducted. This was because the swab was required to absorb liquid or blood at the surgical site. What was the type and duration of procedure? Retained swab events were most common during invasive procedures of the abdomen, such as a laparotomy (a surgical cut into the abdominal cavity). Retained swab events were also more common during colorectal (lower intestinal tract) invasive procedures and gynaecological invasive procedures. Retained swabs events occurred in all lengths of invasive procedure but were most common in procedures that lasted more than 4 hours or procedures that were less than 1 hour in duration. What was the impact of professional culture and practice? There was evidence in some reports of a culture of practice among consultant surgeons of leaving the operating theatre before a procedure was completed. Reports described how the consultant surgeon would perform most of the procedure but hand over to their surgical assistant or registrar (who had often been present for the procedure) to conduct the skin closure. The consultant surgeon would then leave the operating theatre to write up their surgical notes, continue their ward round or see their next patient. This meant that the consultant surgeon was not present when the final swab count was completed, or for the World Health Organization (WHO) surgical safety checklist (World Health Organization, 2009) ‘Sign Out’, when it is confirmed that the swab, instrument and needle counts are complete. Surgeons had also informed the scrub practitioner or anaesthetist that they had inserted a swab temporarily but subsequently left the operating theatre, leaving other members of the theatre team (for example a more junior surgeon) to complete the procedure. Surgeons had been noted to take swabs and/or equipment directly from the scrub practitioner’s trolley without informing them. This had led to surgeons using swabs without the scrub practitioner being aware of this, sometimes after swab counts had been completed. Were there any distractions or interruptions? There was evidence throughout the serious incident reports that staff were distracted, interrupted or their attention was focused elsewhere. This was considered to negatively affect the swab count or staff’s ability to track swabs. Distractions and interruptions in the operating theatre environment included questions or requests from other staff members, the movement of other staff members, conversations, noise, and awareness that the end of the shift was approaching. Were there any competing tasks? Those involved in the swab count could be required to conduct multiple tasks at the same time. Evidence indicates that some multi-tasking may be beneficial to performance. However, too much multi-tasking, especially when tasks are difficult, can be detrimental to performance (Adler and Benbunan-Fich, 2012). Was there time pressure or perceived time pressure? Time pressure meant that tasks could be rushed or missed. Factors contributing to the perception of time pressure included awareness of other cases, including emergency procedures, that were waiting to come into the operating theatre, the surgeon needing to see other patients, a mismatch in the speed at which tasks were being completed between the surgical and scrub teams, and awareness that the shift was coming to an end or had ended. What time of day did the procedure take place? Incidents were more common in procedures that finished in the afternoon and early evening, especially between 14:00 hours and 19:00 hours. Considering the length of the procedures and that retained swab events are more common in the afternoon and evening, it would be beneficial to consider whether fatigue was a contributory factor. However, only one of the serious incident reports reviewed by the investigation considered fatigue. Without further data, it is difficult to draw conclusions from the information provided in the serious incident reports. Previous Healthcare Safety Investigation Branch investigations have found fatigue to be a contributory factor in safety incidents, including ‘ Detection of retained vaginal swabs and tampons following childbirth ’ (Healthcare Safety Investigation Branch, 2019). Fatigue may be subject of future Health Services Safety Investigations Body investigations ( Healthcare Safety investigation Branch, 2023 ). How clear are policies and guidance? Several reports cited that written policies and procedures may be unclear. This included: not specifying times at which counts are to be performed not specifying how counts should be recorded not stating that surgeons should verbalise when they place a swab into, or take one out of, a cavity. Initial findings from this thematic analysis suggest that there are multiple factors that may contribute to the occurrence of a retained swab event and although they are categorised as Never Events under ‘retained foreign objects’ there are currently no ‘strong systemic barriers’ available to prevent them.