Two recent incidents have highlighted when a swab was left inside patients after surgery. In both cases, checks were completed and counts were recorded as correct. However, the checks did not reflect what was still happening around the patient.

• In one case, clinical activity continued after the final count. Additionally another swab was used after the final count and was not included in the checking process.
• In the other, counting, wound closure and clearing away equipment happened at the same time, making the final check less reliable.

Although these incidents happened in theatres, the learning applies to colleagues and teams carrying out invasive or interventional procedures.

What enters the patient or procedure site?

• Think about the procedures undertaken in your area.
• Do you use swabs, packs, guidewires, needles, blades, dressings, catheter parts or device components?
• Which of those items could be missed, left behind or not fully accounted for?
• The first step is knowing which items need to be tracked.

How does the team know they have all been accounted for?

• A check can only include the items the team knows have been used.
• Is it clear who is responsible for keeping track? Are items recorded as they are used? Is their introduction or removal clearly communicated and acknowledged?
• Or does the process rely on one person remembering, noticing or assuming that somebody else has it covered?

When is the risk over?

• Could another item still be used after the final check? Is treatment still continuing? Has the procedure changed? Has anything happened since the last check that means it should be repeated?
• A final check is only final when no further relevant item is expected to enter the patient or procedural field.

What happens if the check is interrupted?

• Safety-critical checks are vulnerable when other work continues around them.
• People may be answering questions, documenting, clearing equipment, preparing for the next patient or dealing with another task.
• Does your team stop and repeat the safety check if it is interrupted, or carry on from memory?
• Is equipment or waste removed before the final check is complete?

Managers are asked to share learning with their teams

This is not about asking every clinical area to adopt theatre counting processes. It is about using learning from one part of the organisation to test the reliability of practice elsewhere. At your next team meeting, safety brief or clinical governance discussion, ask:

• What items do we need to keep track of?
• Who is responsible for checking them?
• When has the risk truly ended?
• What do we do if the check is interrupted or the procedure changes?

The full Patient Safety Incident Investigation (PSII) reports are on the Theatres Never Events intranet page.