Hide and seek, the search for a missing swab: a critical analysis.
Abstract: This article explores the root causes of a missing swab incident. It reinforces the scrub practitioner's responsibility for the surgical count as reflected on by a student operating department practitioner. With environmental pressures and methods upheld by the operating room culture it is recognised that mistakes do sometimes arise from human error when the stress from workload becomes apparent. Through reflection, mistakes can become learning opportunities, as sought through this critical appraisal.
Subject: Surgeons (Aims and objectives)
Surgical errors (Analysis)
Surgical errors (Causes of)
Surgical errors (Prevention)
Author: Bell, Roxanne
Pub Date: 04/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: April, 2012 Source Volume: 22 Source Issue: 4
Topic: Event Code: 220 Strategy & planning
Accession Number: 293545457
Full Text: Introduction

Critical incident analysis (CIA) is an exploration of a significant event in practice which a healthcare practitioner reflects upon in a systematic manner (Ghaye & Lillyman 2010). CIA, according to Rolfe et al (2010), does not have to be based on a life-threatening scenario, as the words 'critical' and 'incident' might imply. It is simply an important memory recall where actions and activities have been encapsulated, provoking practitioners to analyse them. Thus CIA can be defined as a reflective learning technique.

Reflection, as sought by Rolfe et al (2010), is a form of paradigm. It highlights the intertwining relationship between theory and practice, requiring the practitioner to appreciate where they or others lack in knowledge or practical skills. Schon (1991) discusses two forms of reflective paradigms: reflection-in-action which allows you to improve your standard of practice at the time of the event, and reflection-on-action which creates a potential learning situation from retrospective appraisal. Taylor (2006) contends that no form of reflection is better than another. Thus an example of reflection-on-action takes form throughout this article, while an example of reflection-in-action can be viewed in the reflective description of the critical incident.

I appreciate the legality of withholding identifiable information therefore the patient in my incident will remain anonymous while the healthcare providers will be referred to by their roles. This respects the obligations set by the Data Protection Act 1998 as well as my future registrant body, the Health Professions Council, who also enforce the importance of reflection in practice (HPC 2008). Reflection can be a complex process and therefore I will be using Gibbs' (1998) model of reflection to help me structure and transform the knowledge surrounding my incident by breaking it down into stages: description, feelings, evaluation, analysis, conclusion and action plan.

Gibb's model of reflection was based upon Dewey's (1938) model of reflective learning. Dewey's simple model was a review on experience, observation, reflection and knowledge. This framework inspired other educationalists to articulate more comprehensive guided models. Rolfe et al (2010) argued however, that the stages in Gibbs' model are little less than comprehensive as they are non specific and perhaps too vague for a novice practitioner to reflect upon. However, I disagree as I feel this framework is straight forward and easy to follow and allows me to think critically about the event. Bulman and Schutz (2008) agreed that Gibbs' model provides a simple and logical process through reflection.

The formation of ideas effectuating my incident was vast and difficult to collate. A construction of a cause and effect diagram allowed me to delve deeper, exploring the root causes of the incident. A cause and effect diagram is sometimes known as an Ishikawa diagram after its inventor (Doctor Kaoru Ishikawa) or a fishbone diagram because it looks like a skeleton of a fish (NHS Institute for Innovation and Improvement 2008).

The Incident

The incident happened during a morning session of a gynaecological operative list. I was in the role of the scrub practitioner for my first experience of a myomectomy procedure. Our patient had been suffering from the growth of a smooth muscle tumour (fibroid) projecting from the peritoneal surface of her uterus. On abdominal examination prior to the procedure, a palpable mass was clearly seen arising from her pelvis. The procedure aimed to remove the large fibroid by incising through the uterine musculature overlying the fibroid and bluntly dissecting the myometrium from the fibroid pseudocapsule.


The patient's procedure was successful, removing an astonishing 4.1kg fibroid. After the surgeon had closed the uterine incisions to obliterate the dead-space, he began establishing haemostasis. On anticipating that he would soon request a 3.0 PDS suture to close the abdominal wall, I started a full swab, instrument and sharps count. I began by counting two raytec swabs into a clear plastic bag held by the circulator. The bag already contained three raytec swabs: one had been used to disinfect the site for female catheterisation and two had been used to disinfect the surgical site at the start of the procedure. A red tie accompanied the swabs which identifies a completed pack. The second pack of raytec swabs was then counted on my sterile trolley. However in this count, one of the raytec swabs was missing. On a recount, the swab was still missing. I counted through the abdominal and vest swabs to see whether the raytec swab had become wrapped up in the layers of these swabs, however this proved unsuccessful.

In a nervous but nonetheless dedicated disposition I relayed a missing raytec swab alert to the surgeon. He acknowledged this and gently examined the abdominal cavity, but no raytec swab was apparent. My mentor advised the circulator to call a senior member of staff for help and guidance. The circulator donned a pair of gloves to search through the swabs which had already been removed from the sterile trolley. Searching through one pack of five raytec swabs and six packs of abdominal swabs, the swab had still not been retrieved. The circulator and newly arrived senior member of staff then searched through the clinical waste bags and under the operating table in case one had accidently been dropped but the missing swab was not found. The next logical step was to call x-ray, in line with trust policy (2011), as the raytec swab would have a radio-opaque marker which would allow detection. Whilst awaiting the arrival of x-ray a warm swab was used to cover the abdominal organs in order to prevent heat loss through the open wound and to prevent airborne bacteria from potentially causing an infection.


During this period I felt a mixture of emotions; one was of embarrassment in front of the multidisciplinary team, and the other was of failure in the provision of adequate patient care. The procedure had gone well. I felt that I had assisted the surgeon appropriately and safely but when this incident arose, I felt personally responsible for this unnecessary disruption which could potentially cause harm to the patient. The senior member of staff noted a continued loss of operative time in the theatre register and commented that an incident form must be compiled in accordance with trust policy (2010a). They also instructed that someone should see the next patient on the operating list and make them aware that their procedure would be delayed and may even be cancelled if the swab was not found.

Whilst waiting for x-ray to arrive, I was able to 'reflect-in-action'. No raytec swabs were given to the surgeon during any part of the procedure, as only abdominal and vest swabs were used inside the wound. I had also made a mental note at the start of the procedure that I had only six raytec swabs on my sterile trolley. Two had been used for skin antisepsis and two had been used during the catheterisation procedure, however only three had been retrieved in the clear plastic bag by the circulator. I voiced my opinion that perhaps the missing raytec swab could be under the drapes where the surgeon had catheterised the patient. At first the surgeon seemed to dismiss the idea that he had left a swab there, but suggested that we had a look because x-ray had not yet arrived. Safely holding onto my diathermy leads and suction apparatus, the circulator checked underneath the drapes and, to my relief, the missing swab was found. The agitated atmosphere of the theatre seemed to lift as the procedure recommenced and x-ray was informed of the retrieval of the missing swab. The surgeon also praised me, which I sensed was a form of an apology for his disgruntled dismissal of my opinion.


According to my trust's policy (2011), to prevent foreign body retention and subsequent injury to the patient all swabs, instruments and sharps must be accounted for at all times during a surgical procedure. The surgical count becomes the full responsibility of the scrub practitioner and circulator who undertakes it. On completion of the procedure, a verbal statement must be made clarifying: 'swabs, sharps and instruments are correct'. Verbal acknowledgment is required by the surgeon in order to prevent any misunderstanding.

Another measure to prevent foreign body retention is conformance with the 'Safe Surgery Saves Lives' surgical safety checklist (SSC) (WHO 2009). With the vision of improving the safety of surgical care worldwide, the World Health Organisation developed this checklist to encourage the operating team to carry out routine checks during the crucial phases of: 'Sign-In', 'Time-Out' and 'Sign-Out' (Wilson & Walker 2009). In the 'Sign-Out' phase, the surgeon stamps the patient's operating notes to confirm that the surgical count was undertaken, as highlighted by the SSC (Trust local policy 2010b).

According to Vats et al (2009) for checklists to be effective they need to be performed systematically. There is strong evidence to suggest that checklists do improve patient safety and reduce adverse events in the operating theatre. For example, a survey conducted by the Evidence Centre in 2009 showed that from a sample of 167 acute trusts, most reported improvements in patient safety by 32% as a result of adhering to the SSC (Patient Safety First 2011). Despite this, Mitchell and Mitchell (2011) note that adverse events are still occurring in the perioperative environment. These have been mainly due to poor patient care which has resulted in unintended injuries and complications. deVries et al (2008) provide evidence from a systematic review that, of all the adverse events arising in a hospital environment, 41% of them manifest in the operating theatre.

Cuschieri (2006) identifies the 'intensivity factor'. This considers patients receiving a median of 21 'treatment events' collectively from their first arrival in the anaesthetic room through to the recovery area. During these individual treatment events there are more opportunities for adverse events to arise compared to just one treatment event of the patient convalescing from surgery in a ward environment. Those absolute figures may therefore be providing a misleading verdict on the actual occurrence of adverse events in the operating theatre.

In trying to evaluate the situation, I believe that a good aspect was that all the professionals diligently participated and performed all the elements outlined by the SSC. However, I fear that what was bad was a deviation on my part: i.e. not participating in a swab count during the procedure. As Haynes et al (2009) would argue, the effectiveness of professional guidelines will only improve patient safety when they are performed as a whole and not just as the integral elements. This makes me ask the question: with mandatory methodologies and standards set by regulatory bodies, for example the HPC (2008), practitioners must be aware of and conform to any relevant safety policies and procedures in the workplace. Why do practitioners therefore deviate from policies and procedures? According to Dimond (2011) although deviation from professional guidelines is misconduct and may lead to deregistration, codes of conduct are not legally binding. Woodhead (2009) contributes further by reinforcing that the surgical count is as yet not compulsory by law. However we do hold a specific responsibility to our patients in performing the surgical count. Further analysis of the incident follows.

Incident analysis

In order to analyse something, Atkins (2008) suggests that practitioners must try to understand the complex elements surrounding their incident. To do this in a critical manner, the elements must be divided into strengths and weakness then an overall judgement can be made. The first element of an analysis will be that of managing risk in the perioperative environment. According to the AfPP (2009) the key strategy for ensuring patient safety is adhering to frameworks set out by clinical governance and risk management processes. Fullbrook (2005) defines risk as identifying the potential hazards which determine the recurrent probability of adverse events and discovering the magnitude of the consequences which may arise. In order to manage risk, Scott and Summerbell (2004) stipulate that practitioners must follow these three processes when risk arises to prevent further adverse events from occurring:

* report and investigate incidents so that practitioners can learn from them

* ensure that practitioners are 'risk aware'

* ensure that human errors are not repeated.

During the incident a senior member of staff requested an incident form to be compiled due to the loss of operating time. Subconsciously I queried whether the member of staff was thinking about the safety of our current patient or whether the list was going to overrun. A citation from Vats et al (2009) presents the exact connotation of the situation at the time. They assert that, with more than 8 million surgical operations undertaken in the UK alone, there is a heightened pressure on surgical services to constantly try to reduce waiting times whilst embracing a quicker turnover of patients. Surgery can now be compared to an assembly line in industrial manufacturing. Reid and Clarke (2009) contribute further by debating the safety of surgical procedures. They surmise that procedures are intended to save and improve the quality of patients' lives, but due to frequent mistakes more patients are submitted to substantial harm.

A formula devised by Pandit et al (2007) sought ways of minimising mistakes and improving the efficiency of operating lists by maximising theatre utilisation, minimising over-running and minimising cancellations. The AfPP (2007) highlights recommendations for achieving these elements. It suggests that the consultant operating surgeon or senior scheduler must allow for three and a half hours operating time and half an hour for the postoperative recovery of the patient and effective decontamination of the theatre. Although not all procedures will need this operative time, consideration for patients with complex co-morbidities must be made in the anticipation of any critical events (major blood loss) (Vats et al 2009). Pandit and Carey (2006) stipulate that planning operating lists in this manner would then reduce the incidence of predictable overruns and cancellations.

It has been estimated that the majority of the operating lists over-run; this equates to about 5% of the capacity of all hospitals in the UK (Audit Commission, 2003). A study carried out by Pandit and Carey (2006) found that, although surgeons and senior schedulers were accurate in estimating the actual duration of procedures, they were poor at booking these procedures into the scheduled duration of the operating list. Furthermore their survey of 50 consecutive published surgical lists found that 50% of the lists were predictability overbooked, and that 50% overran their scheduled time. This resulted in 34% of the lists having to cancel their patients.

In a recent five year observational study of 978 patients who were cancelled on the day of surgery, the second most major cause (207 patients cancelled) was due to the theatre list over-running (Rymaruk 2011). According to guidelines set out by the AfPP (2007), in situations where the operating surgeon has run out of allocated operating session, a senior member of staff should cancel any further cases to prevent the list from over-running. An incident form must then be completed stating the reason for the cancellation. Now I can fully appreciate why the form was compiled. The senior practitioner was coordinating the operating list to professional guidelines. We had been efficient with our patient turnover, but no one could have anticipated a swab going missing thus causing the cancellation of our last case.

Incident reporting is not about practising a blame culture but aims to establish an open and fair one. This would encourage staff to share information within their trust when things go wrong allowing key risk areas or 'one off' incidents to be identified which could actually be 'one off' incidents repeated throughout the trust (Scott & Summerbell 2004). Risk assessments to consolidate a solution to the root cause of the problem could then be implemented (Edwards 2005). Reporting patient safety incidents can become a learning opportunity; practitioners need to feel valued not blamed and we all need to realise that we are only human and that errors can happen (Scott & Summerbell 2004).

This reminds me to analyse the aspect of human error which affected my incident. Dekker (2005) defines human error as being the result of environmental, organisational, personal or work associated constraints that cause humans to behave unpredictably in stressful situations. Patient Safety First (2009) accepts that high pressure workloads can be stressful and may result in either a lack of focus on the task at hand, or being overly focused on the task at the expense of the wider context. This is called fixation: in order to cope with a stressful situation we submit our full attention to it (Bromiley & Mitchell 2009).

Providing an overall judgement, these citations have captured the root causes of my incident coherently. I was fixated on learning the anatomy and stages of the procedure whilst my mentor was focused on assessing my practice. The surgeon was fixated on starting the procedure under the pressure of his completing his operating list within the scheduled operating time and the circulator had failed to retrieve the swab because of heightened pressure of coordinating their host of duties. When the swab was alerted missing, the atmosphere grew tense. This prevented practitioners from stepping back and revising the situation. Whilst waiting for the X-ray, the team was able to 'calm down'; enabling 'reflect-in-action'. According to Patient Safety First (2009) in such circumstances, a 'time out' must be conducted for the whole team to gain a better awareness of the situation. Bromiley and Mitchell (2009) affirm two solutions when fixation occurs. Firstly practitioners must have the ability to assert themselves clearly and the second is the ability for others to listen and accept help. I relayed my opinion on where the swab may have been which was dismissed at first and then accepted by the surgeon.


In order to draw a conclusion, I would like to highlight the ethicolegal aspects of retained items. According to Gawande et al (2003) the most common intra-abdominal retained item is a swab, with the estimated incidence of 1 in every 1,000 to 1,500 operations. This equates to a 69% re-operation rate, with 2% risk of mortality due to sepsis and fistulae.

Although extremely rare, there has been the seldom-reported condition of a Gossypiboma. This Latin term denotes the concealment of a cotton foreign body that has been left undetected inside a patient's body. Over time the foreign body becomes inert due an aseptic fibroblast reaction. Fibroblasts are large flat cells that encapsulate a shield around the foreign body by secreting collagen and elastic fibres binding the surfaces of the cotton body together. Phagocytes (white blood cells and macrophages) then migrate to the body, engulfing and digesting the bacteria and cell debris created by the fibroblast activity. Some patients are asymptomatic whereas others experience abdominal pain. In most cases the problem is misdiagnosed leading to the unnecessary treatment of 'other ailments' and other complications arising subject to mortality (Gencosmanoglu & Inceoglu 2003).

The prospect of retained items falls under the 25 listed 'Never Events' (DH2011). A Never Event should never happen. It occurs when policies and procedures have not been implemented resulting in a serious and yet preventable patient safety incident (NPSA 2010). When Never Events happen they draw media attention and censure the surgical community, damaging the confidence and morale of practitioners especially when risk of litigation is upon them (Vats et al 2009). In English law all health practitioners are legally and morally accountable for the duty of care they bestow upon their patients (Boylan-Kemp 2009). Quick (2010) highlights that, when the duty of care has been breached resulting in foreseeable harm, the patient can claim the tort of negligence. The law of 'tort' (injury or wrong committed to a person) includes negligence when suffering is caused. The patient (plaintiff) is entitled to claim the expenses they have incurred during the first and subsequent treatment periods. The doctrine of res ipsa loquitor (latin for 'things which speak for itself') passes the legal judgement when negligent practice has been evident.

In 1995 NHSLA (2011) set up the voluntary Clinical Negligence Scheme for Trusts. This monitors the number of claims made by patients relating to hospital incidents. Out of 14 hospital specialities, the highest number of claims was made towards the surgical provision, with 25,867 claims to date. In essence this scheme was introduced to help aid change as brought about by the modernisation of the NHS in 1997 by the Labour government. They termed this strategy Clinical Governance, setting out to achieve six key principles:

* to deliver high quality care to all patients

* to establish national standards based upon best practices

* to collaborate team work between hospitals, community services and local authorities where the patient is the main focus

* to ensure that the service considers associated costs providing value for money

* to establish a culture where clinical quality is guaranteed for all patients

* to enhance public confidence in the NHS (McSherry & Pearce 2011).

Action plan

With the view of clinical governance to aid my action plan, I have reviewed my trust's procedure (2010c). It states that the clinical equipment to be used is a dressing pack which contains cotton wool balls for disinfection. I recommend this method is made clear to all theatre specialities to ensure standardisation preventing a similar incident from reoccurring. The incident caused operative time to be lost, the last patient to be cancelled, the theatre to be under-utilised with the associated cost, the patient to being anaesthetised for longer than was necessary, and potentially to be exposed to ionizing radiation.

The forefront of this article has been the retrospective appraisal of a negative incident in practice. Through CIA (a reflective learning technique) with the aid of Gibbs' reflective model and the utilisation of a cause and effect diagram, I have critically explored and identified the root causes of the incident. The knowledge I have obtained and demonstrated relays the importance of abiding by local and national policies and procedures, detailing the role of the scrub practitioner in the responsibility of the surgical count. By reflecting upon the environmental pressures and methods upheld by the operating room culture it has become recognised that mistakes are made from human error when the stress from workload becomes apparent. It is therefore necessary to slow down and benefit from a learning opportunity, remembering the key principles of clinical governance in delivering high quality patient care from an ethicolegal prospective.

From developing an awareness of managing risk in the perioperative environment, the logical aspect would be to look on the positive side of the errors. So long as we create a culture of catching small errors by employing risk assessments and incident forms we can prevent more significant mistakes from occurring, thereby ensuring that human errors are not repeated, and promoting patient safety within our duty of care.


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About the author

Roxanne Bell


Student ODP, Cambridge University Hospitals NHS Foundation Trust, Cambridge

No competing interests declared

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KEYWORDS Risk assessment / Incident reporting / Root cause analysis

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication January 2012.

by Roxanne Bell Correspondence address: Roxanne Bell, Theatres, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ. Email: roxanne.bell@addenbrookes.nhs.uk
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.