Safety recommendation
Original safety recommendation:
HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) 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.
Updated safety recommendation following engagement:
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.
Response:
CPOC undertook a full review of the National Safety Standards for Invasive Procedures (NatSSIPs) commissioned by NHS England, and published in January 2023. The AfPP is a board member of CPOC, and we had representation and extensive input from AfPP when writing the revised NatSSIPs.
It is both CPOC and AfPP’s stance that the NatSSIPs should be implemented in full and would likely be more impactful should organisations such as NHS England and equivalent in the devolved nations mandate them as a component part of the commissioned services.
NatSSIPs consists of organisational standards (such as whole team training, induction, data collection, audit trails) and sequential standards (the steps that should happen for each patient). Unfortunately the HSSIB recommendation as written reinforces a message that the scrub practitioner could be more efficient if additional standards are written, reinforcing the blame culture. Both CPOC and AfPP (along with many Human Factors experts) feel that this approach is strongly flawed.
We look forward to our formal response being published on the HSSIB website and social media channels as per your letter dated 12 April 2024 and we would be happy to co-ordinate our to communication plan with yourselves.
Response received on 21 June 2024.
HSSIB has engaged with Centre of Perioperative Care (CPOC) and the Association for Perioperative Practice (AfPP) throughout the investigation. HSSIB received the response to the recommendation on 21 June 2024 and noted that the response did not meet the intent of the safety recommendation. However, HSSIB has taken feedback from CPOC and AfPP into account to acknowledge the continuing collaboration between the two organisations. HSSIB has made adjustments to the recommendation and the report where appropriate but unfortunately neither organisation feel able to amend their response. We hope that both organisations are able to embrace our recommendation and identify opportunities to learn from our report in their on-going work to improve patient safety and care.