Ep 9 - HSSIB Retained Sponges Report - Part II
Show notes
This is part 2 of a 2 part series discussing the UK Health services safety investigations Body and their Retained Sponges report.
Summary of part 1:
The Health Services Safety Investigations Body (HSSIB) investigates patient safety concerns in the UK. They are an independent body with the aim of making healthcare safer.
The report uses a reference case where a patient, Helen, had to go to the OR 3 times total for retained surgical sponges
Although no specific cause for why the sponges in Helen’s case were retained, this event was very illustrative on how these types of errors can occur and was instrumental in producing the report
The report, and our discussion of it focuses on the count, and reconciliation, discusses the concept of “never events”, factors affecting the sponge count, factors affecting the detectability of sponges in Helen’s chest, why the sponges were not initially identified on Chest X-Ray, and factors affecting the detection of the second retained sponge
We also discussed the Hierarchical Task Analysis along with findings of the wider investigation
In this episode we will be building on our previous discussion and look at the second part of the report that discusses risk management principles in safety critical industries
Risk management principles:
Key elements of risk management
Identifying hazards, or risk identification
These are the things that could cause harm or problems
assessing the risk
The likelihood of a hazard causing harm
Putting in place controls or making a decision
Implementation of solutions that lead to risk reduction or prevention
Documenting the management decisions
A recording of the findings and outcomes of your intervention; if you don’t measure it, it doesn't matter
Allows you to keep track of efficacy of changes
Cyclical review
Check if old interventions are still valid or if there is a better way of risk management now
There is not the expectation that all risk will be eliminated but the goal is to reduce the risk to “as low as reasonably practicable” (ALARP)
The utility of this framing is that it helps set reasonable limits on the degree of intervention needed to address a problem. The example used in the report is “An extreme example is that spending £1m to prevent 5 staff suffering bruised knees would be considered grossly disproportionate”
This allows us to frame successes as reductions in adverse events rather than a total elimination of some events that are unavoidable
The UK’s Health and safety executive, their national regulator for workplace health and safety actually sets a guideline for acceptable risk: death of one in a million per year for both workers and the public
The utility of having this put out by a national board sets a benchmark for comparison
The HSSIB performed some back-of-the-napkin math and found that in 2013 there were approximately 4.7 million surgeries conducted in the NHS per year. Then using the data of reported unintentional retained sponges, they found that the average was one incident every 270,115 surgeries. Since it was not known whether anyone had ever died of a retained sponge, they used a conservative estimate of 1 in 10 retained sponges resulting in death.
This resulted in a “risk to life” (RtL) of < 1 in 1 million, which indicated that based on the HSE”s tolerability framework, the risk of harm may be deemed to be at an acceptable level for healthcare organizations.
The use of tools and technology for reconciliation
The report provides some recommendations and comments regarding the way the count is currently conducted and they break it down into technical and non-technical tools
Non technical tools
The manner in which each scrub nurse laid out their scrub table allowed many of them to immediately identify a missing sponge; “Swabsafe” trays with specific placeholders for used swabs, but these were not favoured by everyone; other tools.
Technical tools
Radiofrequency identification (RFID) tags (preferred by HSSIB who noted that this measure has been adopted in the US for this purpose)
Read multiple tags simultaneously
Can be read when out of sight (e..g in the human body) at > 10m
Many studies in the US showing they can reduce the number of retained sponges and improve the efficiency and effectiveness of the count, as well as reduce costs.
Barcoding - swabs in and out, but must be scanned
The findings of the HSSIB retained sponges report
A range of interrelated system factors (tools, technology, organisation, task, environment, and people) influence the reliability of the sponge count.
The reconciliation process has not been formally analysed or designed using human factors expertise (where the interactions between people and other elements of the system in which they work are explored) or any other process design expertise.
Other safety-critical industries assess and control risks to be ‘as low as reasonably practicable’ (ALARP), where there is not an expectation to eliminate all risk. These risk management principles have not been applied to the risk of swabs being unintentionally retained.
There is no accountability framework, and it is unclear who owns the risk for retained swabs and reducing the risk for retained swab events to as low as reasonably practicable.
Blame can be inappropriately placed on scrub nurses or surgeons when an item goes missing, rather than the reconciliation process being seen as a team activity and one that can be influenced by a wide range of interrelating factors.
Staff and national organisations had varying views on the roles and responsibilities for swab reconciliation; limitations in training were identified.
The investigation was told by various national organisations that there is a concern about removing Never Events from the NHS’s framework and how determining risk appetite (where it is accepted a level of harm will occur) will be perceived by the wider public.
The design of swabs does not help staff to locate, identify, or track swabs during the reconciliation process.
There are technologies and tools that could be used to improve the accuracy of the swab count; however, these have not been embedded into UK healthcare.
The technology and tools have not been formally considered using risk management principles in terms of reducing the risk to as low as reasonably practicable, or how the technology could reduce other patient safety concerns while also supporting productivity and efficiency in healthcare.
HSSIBS Recommendations
“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.”
“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.”
“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.”
HSSIB Safety Observations
“Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.”
“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.”
“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.”
“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.”
Health Services Safety Investigations Body (HSSIB) reports
HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023)
HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021)
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