NHS England
HSSIB recommends that NHS England incorporates the findings of the interim report into its review of the Never Events policy, with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events.
NHS England launched the public consultation into the Never Event framework in February 2024, which incorporates the findings of HSSIB’s interim report ‘Retained surgical swabs: themes identified from a review of NHS serious incident reports’.
The consultation is being held following the findings of reports from the Care Quality Commission (CQC) and HSIB/HSSIB that highlighted for several types and sub-types of Never Events the barriers are not strong enough to make an incident wholly preventable, as well as further focus groups including one in relation to ‘retained foreign object post procedure’ held by the National Patient Safety Team throughout 2021/22.
The consultation asks for views on whether, on balance, the Never Events framework is still considered an effective mechanism to support patient safety improvement; and for a preferred option for its future to be selected. The consultation closes on 5 May 2024, with the initial findings expected to be published in Autumn 2024.
Response received on 28 February 2024.
Association for Perioperative Practice |
Centre for Perioperative Care
HSSIB recommends that the Centre for Perioperative Care and Association for Perioperative Practice work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using 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.
NHS England
HSSIB recommends that NHS England develops a framework to assess whether risks, such as retained swabs, are acceptable, tolerable and have been reduced to as low as reasonably practicable. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance.
National Institute for Health and Care Research
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.