The process used by surgery teams to ensure nothing is left behind in a patient’s body following an operation should be reviewed, the patient safety body has said.
It comes after one woman who had heart surgery had to have further operations to remove two swabs left behind in her chest.
Swabs being left in patients after an operation are classed as “never events” by NHS England – a serious incident that is entirely preventable due to national guidelines putting safety barriers in place.
However, a probe by the Health Services Safety Investigations Body (HSSIB) found there has been between 11 and 23 incidents every year since 2015.
Operating theatre teams keep track of the amount of swabs used during a procedure by counting them in a process known as reconciliation.
HSSIB said this should be reviewed to account for a “range of complex and interrelated system factors” that can “routinely influence” its reliability.
These factors include the design of the swab itself, as well as the operating theatre being particularly noisy or busy, or teams potentially counting various surgical items while preparing other surgical equipment.
Current NHS waiting lists could also be putting teams under pressure.
Saskia Fursland, senior safety investigator at HSSIB, said: “What we have called for in our report is for those working in healthcare to think differently about the issue and apply a view of the whole system that underpins the process – examine all the factors that influence the swab counting rather than just focusing on individual actions or behaviours.
“We have also reinforced that the healthcare system must continue to look at how they assess and manage risks and maintain the right balance between safety, and other priorities such as financial costs, productivity, and efficiency.”
HSSIB highlighted that the reconciliation process has not been formally analysed and has no risk management principles.
There is also no accountability framework, the report said, with blame “inappropriately placed” on scrub practitioners or surgeons when an item goes missing, rather than the reconciliation process itself.
HSSIB recommends that NHS England develops to explore whether risks, such as retained swabs, are “acceptable, tolerable and have been reduced to as low as reasonably practicable”.
It also called on the National Institute for Health and Care Research (NIHR) to assess the feasibility of commissioning research that will explore if technology could help reduce the risk of retained swabs.
An NIHR spokesperson said: “The NIHR and NHS England work closely with HSSIB to support the development of research recommendations within their investigations.
“Following the publication of this report, the NIHR will consider the research recommendation and assess the priority and feasibility of commissioning research through the standard NIHR research commissioning processes.”
Elsewhere, the HSSIB said the Centre for Perioperative Care and Association for Perioperative Practice should work with stakeholders to review and amend the reconciliation process using human factors expertise and user-centred design principles to reduce risks.
Ms Fursland said the recommendations “are aimed to influencing safety improvements, not just for swabs but any item used in surgical procedures, and at encouraging a different approach that could lead to sustained change”.
The HSSIB also made a number of safety observations, including that manufacturers can improve patient safety by making swabs easier to detect.
The body’s investigation involved a real-life patient safety incident, as well as interviews, a focus group with NHS theatre staff and observations at an NHS trust.
Helen, 59, had an operation to treat coronary heart disease, which took about five hours and involved opening up her chest.
An x-ray after the procedure showed a swab had been left inside her chest, which had to be opened up again to remove it.
Following this, another chest x-ray found a second swap remained in her chest.
Ms Fursland added: “Retained swabs, as with any retained foreign object after surgery, can lead to physical and psychological harm for patients.
“When we spoke to Helen six months after her incident, she was still visibly upset and struggling with the mental effects.
“Whilst the number of retained swabs appear relatively low, they continue to occur and there has been up to 23 patients in a year experiencing an incident and the negative patient outcomes that can come with it – from distress and trauma, the risk of infection, to further surgery and prolonged hospital stays.”
Mr Tim Mitchell, president of the Royal College of Surgeons of England, said: “It is very rare for a surgical swab to be left in a patient after surgery but when it does happen it can be incredibly upsetting to the patient and can lead to serious complications.
“More needs to be done to develop a true learning culture in the NHS that allows staff to learn from mistakes rather than just apportion blame.
“We will support any review of the process and standards for the reconciliation of swabs which supports the aim of helping to prevent future mistakes.”
An NHS spokesperson said: “NHS staff work exceptionally hard to keep patients safe and thankfully incidents around retained swabs are extremely rare. However, when they do occur trusts are mandated to investigate what has happened and take effective steps to improve as part of the NHS’s patient safety procedures.”
The Department of Health and Social Care has been approached for comment.
