Retained swabs? A never event or a 'clever' event that has the potential to act as a fundamental driver to improve practice and systems.
Abstract: 'Never events' are definable, known sources of risk for which there is existing national guidance and/or safety recommendations on how the event can be prevented, there is support for implementation and as such should be largely preventable if the guidance is implemented (DH 2011)
Article Type: Viewpoint essay
Subject: Medicine (Practice)
Medicine (Analysis)
Medical care (Quality management)
Medical care (Analysis)
Author: Coates, Tracy
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
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 293545449
Full Text: There is an extensive list defined as never events covering all aspects of clinical practice. However, you cannot fail to notice an increase in the media of stories of retained swabs particularly. The statement from the Department of Health sounds so matter of fact doesn't it? And yes of course we would all largely agree, but not clear in this sentence are the human factors that ebb and flow through our daily practices. There have been counting policies in place for many years and there is increasing technological support, but the problem will always be affected at the level to which practitioners abide by the process, deviate as professional judgement and be affected by human factors (e.g. distraction, fatigue, rule/knowledge based mistakes). The natural response is to defend the counting practice as the patient would have not left the theatre, or it would have been recorded if the count had been incorrect and further investigations taken.

Contact with members through my professional role as the Association's president and my independent work has identified situations where teams are trying to come to terms with being involved in a case that subsequently results in a retained swab. The effects on individuals cannot be underestimated as they personally dissect their actions and struggle to come to terms with an error they may have made. Equally difficult are the ones where documentation supports a correct count, however, this was clearly wrong as the patient has a subsequent discovery of a swab inside. This could have happened recently or indeed in the patient's past history if it involves multiinterventions. There is no dispute that a responsibility of the scrubbed practitioner is to ensure that every counted item at the beginning of the procedure is there at the end, and individuals require support systems to achieve this in the notoriously pressured perioperative environment.


Has it happened to you? Will it happen to you? What will you learn from it? What are you doing to prevent it happening? This will be within the governance and leadership that sits within your organisation and its safety culture. You, however, also play a big part in all the processes that prevent it, manage it, learn from it and care for colleagues that will be involved in it. I would suggest that you make it your responsibility to consider your practice and system support as you act as a scrub practitioner in your work place, ideally before it happens to you.

If you are involved in a retained swab incident don't panic. Investigation will be rapid in the first instance as it is defined as a never event. If it is identified that you had made an error or omission then the consequences may be formal and you may need some workplace support. However, a thorough formal investigation of the root cause will be the opportunity to see the whole picture and the factors that will have contributed to it. Your feedback will be vital to this process. Subsequent management of the incident should reflect the whole investigation and will probably include a range of factors within the action plan. Regulation and professional codes are there to protect the public. Acknowledgement of this should be coupled with recognition of human error and an ethical and equitable approach to managing the improvement and learning process and dealing with any damaged individuals involved, patients and staff.

There will always be a risk of retention of any item due to human factors. A robust policy, supported by visual aids, education, standardisation, good safety governance and supportive non-penalising personnel management and personal responsibility when incidents occur, should help us all towards that zero goal.

RELATED ARTICLE: Top tips for prevention

Is there a swab counting policy? Do you know how to access it and is it included as part of the education packages for new staff and on-going updates for existing staff?

Is there compliance with the policy from staff - if not why not? Is there a need to review it now?

Is your environment conducive to safe counting - have you standardised techniques and recording?

Which staff are identified as being able to participate in count and have they received appropriate training and defined responsibilities and supervision if required?

Do you discuss the counting procedure in briefing?

* Are plans for staff resources and changeover and rest period discussed to enable a robust transition of count agreed within the team? Recommended practice (AfPP 2011) is to risk assess any procedure over 6 hours for scrub and circulator

* Will it be agreed to have silence, noise reduction or a pause as the counts are being undertaken?

* Do you discuss what will be your actions if a swab is unaccounted for (this may prevent movement of patient to another area or waking up) and further intervention?

* Who will be the lead surgeon to receive the final count confirmation with scrub practitioner and agree the language that will be used to prevent misunderstanding?

Do you have additional count support equipment e.g. plastic trays pocketed bags if so are all the swabs (used or unused) placed together to enable the final count before discarding all together?

Is sign out consistently practiced?

* This can be an opportunity for the team to confirm that all appropriate counting benchmarks have been completed


* Do you celebrate near misses -i.e. identified missing swabs and subsequent location in your theatre meetings and share and learn from these events to all teams and departments where surgical interventions are practiced?


Department of Health 2011 The "never events" list 2011/12 (Online) Available from: [Accessed March 2012]

Further reading

Association for Perioperative Practice 2011 Standards and Recommendations for Safe Perioperative Practice Harrogate, AfPP

Department of Health 2012 The "never events" list 2012/13 (Online) Available from: [Accessed March 2012]

Nothing Left Behind Available from: [Accessed March 2012]

Association of periOperative Registered Nurses 2010 Recommended practices for sponge sharps and instrument counts. In: Perioperative Standards and Recommended Practices Denver, AORN Inc

WHO Patient safety Curriculum Guide Available from: [Accessed March 2012]

About the author

Tracy Coates


President, The Association for Perioperative Practice, Harrogate

No competing interests declared

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by Tracy Coates

Correspondence address: Tracy Coates, President, Association for Perioperative Practice, Daisy Ayris House, 42 Freemans Way, Harrogate, HG3 1DH. Email:
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