Ep 8 - HSSIB Retained Sponges Report - Part I

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Show notes

• The reference event: Helen’s CABG
  • Helen had heart surgery (CABG x3 “triple bypass open heart surgery”).
  • The day after the procedure, Helen had trouble breathing and a Chest X-Ray (CXR) taken for another reason, identified a retained sponge.
  • She was taken back to the OR and had the sponge removed. As she was quite unstable, the decision was made not to X-ray her in the OR and to close her chest and stabilize her. At 7:30 pm, a CXR identified a second sponge in the same location as the first. The following morning, she had another surgery to remove the swab from her chest. A CXR performed in the OR showed no foreign objects.
  • Helen was in the ICU for 7 days and was discharged 13 days after her final surgery to remove the second sponge. At home, Helen had ongoing health problems. Helen’s family referred the incident to the HSSIB.
  • When the investigators first met Helen six months after the incident, she was visibly upset by what had happened and she reported she had received limited mental health support. According to the report, Helen continues to have health and wellbeing issues.”
• Background
  • Investigation began: Sep 28, 2022.
  • Interim report: Dec 7, 2023 (14 months later) highlighted common themes in 31 serious incident reports (investigations carried out by local healthcare trusts).
  • Final report: Apr 16, 2024.
• Never Events
  • Defined as ‘patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at national level and have been implemented by healthcare providers’ (NHS Improvement, 2018).” [emphasis added]
  • Multiple UK reports call for Never Events to be renamed because the events described are not entirely preventable, there are not strong barriers available to prevent them, and by calling them Never Events, it invites stigma and shame and discourages reporting and thorough investigation.
• “The count” / reconciliation
  • Sponges are counted in a specific way, by two nurses, who must agree on the count before the sponges are used
• Analysis and findings regarding the reference event (Helen’s CABG)
  • The HSSIB: “Limitations in the evidence meant it was not possible to identify precisely what happened during Helen’s surgery to result in two swabs being retained."
  • It is curious that the first finding of this report is that the available evidence made it impossible to determine precisely what happened during Helen’s surgery, yet there is no mention of recording devices in the report. In aviation, they had to invent a robust means of recording what occurred in order to determine what happened and how to prevent future accidents. In this case, OR Black Boxes would almost certainly have provided the evidence needed. Patients continue to be placed at risk by the unavailability of this information.
  • Factors affecting the sponge count
    1. responsibility for swab counts (surgeon vs scrub nurse)
    2. communication of information about swabs
       • Surgeons not informing scrub nurse when a sponge was inserted
    3. visibility of swabs
       1. Not in direct line of sight
       2. Soaked with blood and therefore lacking contrast with surrounding tissue
       3. Radiopaque stripes appear similar to other lines on XR and when an XR is performed for another reason, no one is looking for a sponge.
    4. the make-up of the operating theatre team
    • When there is a change of nurses, the count wasn’t always being conducted between the outgoing and incoming nurses
• the timing of the count and its confirmation at Sign Out
• the type and duration of the surgical procedure
• professional culture and practice
  • Surgeons taking swabs directly from the nurse’s table without informing the nurse.
• distractions and interruptions
• competing tasks (counting while doing other tasks)
• time pressure
• time of day
  • More common in surgeries between 2 pm and 7 pm, raising concerns of fatigue (HSSIB noted further data are required here)
• clarity of policies and procedures - lack of clarity on specific times counts are to be performed
• The report again identifies weaknesses in the level and quality of the evidence available in the investigation and finds that there may be other factors that affect the reliability of the count that could not be identified because of that.

• Factors affecting the detectability of the sponges in Helen’s chest
  • Sponges come with tails, but these were cut off before the sponges were used.
  • Sponges absorb blood and then look like tissue.
  • Sponges can be very deep in a cavity and be obscured from view by organs.
• Factors affecting the detectability of the sponges on x-ray
  • There were many other items visible on the CXR (tube, lines etc) making the sponges more difficult to detect.
  • The clinicians were focused on other theories for Helen’s deterioration.
• Factors affecting detection of the second retained sponge 
  • Staff thought there was only one sponge.
  • Helen was unstable and it was deemed unsafe to conduct an extensive search of the chest cavity or an X-ray.
• Analysis and findings of the wider investigation
  • The low frequency of retained foreign objects following invasive procedures indicates that the counting system is largely successful, however, counting items is not a strong systemic barrier.
  • There is a tension between spending more time on something that seems to be largely working well (the count) and the need to be efficient with operating room time (or else harm comes to patients).
  • HSSIB explicitly identifies the conflict that is present in frontline healthcare workers’ minds: ‘every minute that is spent attempting to improve a process that works most of the time is a minute of OR time that another patient cannot receive’
  • The HSSIB resolves this tension by pointing out that while ‘Frontline workers generally operate under rules and procedures which provide a normative standard against which their behaviour can be judged. In contrast, designers, managers, and such generally operate with more degrees of freedom.” Meaning we may be able to design better sponges and use system measures rather than people-focused measures to reduce this risk without a tradeoff.
• OR Black Boxes & Medical Culture (Patreon-only)

Safety intervention worth mentioning: The Hierarchy of Intervention Effectiveness (see diagram)

1. In North America, medical culture places the emphasis on the frontline staff to get it right and when incidents are made known to staff, there is an expectation that that awareness should be sufficient to prevent it from recurring. This is as opposed to changing the working conditions, which is Professor James Reason’s main conclusions in his life’s work.
2. In the interim report, the HSSIB refers to “The Hierarchy of Intervention Effectiveness” from Cefazzo and St-Cyr, 2012, which shows various interventions and their relative effectiveness.
3. “The hierarchy is a tool for ranking the effectiveness of measures used to reduce the risk of a safety event. Measures that rely on people are considered to be less effective.”
4. The solution is to change the working conditions 

Health Services Safety Investigations Body (HSSIB) reports

1. HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
2. HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023)
3. HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021)

Other resources

1. Willful Blindness by Margaret Heffernan
2. Selective Attention Test (Simons & Chabris, 1999, YouTube) (1 min)
3. Cognitive bias in diagnostic radiology (radiopaedia.org)

Random recommendations

1. Adam: Go see the RCAF Snowbirds! 2026 Schedule
   1. Snowbirds to be grounded after the 2026 season until 2030 when they acquire new aircraft

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