Source · HSSIB Patient Safety Investigation

Investigation report: Retained swabs following invasive procedures

Published 16 April 2024 Published

Medical devices Checking Surgical

Full online version of the Health Services Safety Investigations Body (HSSIB) report 'Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports'.

View on HSSIB ↗ · Download Report PDF ↗

Summary

3 recommendations 4 observations 2 of 3 responded

Safety Recommendations

3 total

R/2024/022 Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP)

HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors expertise and user-centred design principles, to reduce the risk of retained swabs to as low as reasonably practicable. Any changes to either organisation’s processes should consider potential unintended consequences and the influence on other safety-critical tasks and include consideration of professional roles and responsibilities in relation to swab reconciliation. Updated safety recommendation on 3 October 2024: HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) continue to work together with other key stakeholders to review, amend and embed the process and standards for the reconciliation of swabs ensuring it is robust. This review should utilise human factors expertise and user-centred design principles, to reduce the risk of retained swabs to as low as reasonably practicable. Any changes to either organisation’s processes should consider potential unintended consequences and the influence on other safety-critical tasks and include consideration of professional roles and responsibilities in relation to swab reconciliation. Original

No response published on HSSIB's website

R/2024/023 NHS England

HSSIB recommends that NHS England develops a framework to assess whether risks, such as retained swabs, are acceptable, tolerable and have been reduced to as low as reasonably practicable. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance. Updated safety recommendation on 23 October 2024: HSSIB recommends that NHS England develops a framework to assess whether risks, such as retained swabs, are reduced to an acceptable level. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance.

NHS England is exploring how safety management system principles can be applied in healthcare, including patient safety risk management. Outcomes of this collaborative work will inform future frameworks for assessing risks like retained swabs.

Response received 25 September 2024

NHS England is working alongside colleagues from across the healthcare system (including HSSIB), academia and other safety critical industries to explore how principles of safety management systems may be translated within a healthcare context. This includes consideration of the management of patient safety risks. The NHS England National Patient Safety Team will consider the outcomes of this work to support decision making in developing any future framework or approach to patient safety risks. Response received on 25 September 2024. HSSIB engaged with NHS England and amended their safety recommendation to include their feedback. HSSIB will continue to work collaboratively with partners to support the development of Safety Management Systems in healthcare which provide a proactive approach to managing safety and set out the necessary organisational structures and accountabilities.

R/2024/024 National Institute for Health and Care Research

HSSIB recommends that the National Institute for Health and Care Research assesses the priority and feasibility of commissioning research to review the viability of implementing technology that could support reducing the risk of retained swabs. The review should balance patient safety, costs, benefits, design, implementation, and the various ways in which the technology could be used to reduce other patient safety concerns to as low as reasonably practicable.

NIHR committed to assessing the priority and feasibility of commissioning research into technology for retained swabs through its established processes, aiming to define a research question and commissioning route by late 2024. All actions were completed by May 2026.

Response received 15 July 2024

The National Institute for Health and Care Research (NIHR) funds health and social care research that improves people’s health and wellbeing. Working with those who use, plan and deliver health services in the UK, we identify and prioritise important topics to fund through specific calls for research. Following referral from HSSIB, the safety recommendation for ‘Retained swabs following invasive procedures’ will be considered through the NIHR’s established research commissioning processes with the aim of generating high-quality evidence to support decision making. After an initial ‘in-house’ assessment of the topic to determine what is already known (the existing evidence base), we will engage with a wide range of individuals with a broad spectrum of knowledge, skills and expertise to agree the most appropriate mechanism to address the outstanding uncertainties. This may result in the development of a new NIHR commissioned call for research or progression of the topic through one of the existing NIHR programmes or infrastructure. Actions planned to deliver safety recommendation: NIHR review recommendation and aim to develop a tractable research question, by approx May - June 2024. This activity will include an in-depth review of the current evidence base which may identify existing research studies which already address the evidence gap/question and therefore negate the need for further primary research. NIHR agree most appropriate commissioning route, by July 2024. Recommended commissioning route approved by relevant NIHR Programme Director, by September 2024. If approved, next steps include development of a call specification or alternatively progression of the topic through one of the existing NIHR programmes or infrastructure, by Sept/Oct 2024. This date may be subject to change. Response received on 15 July 2024. -------------------------------------------- May 2026: HSSIB has been notified by the National Institute for Health and Care Research that all actions have been completed.

Safety Observations

4 total

Observation 1 Observation Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.

Observation 2 Observation 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.

Observation 3 Observation 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.

Observation 4 Observation 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.