Risk of surgical swabs being left inside patients

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: