Friday, 7 August 2015

Surgical Swab - tail it, tag it, secure - then let us see how many are lost

Retained Swab after surgical procedures

Surgical Swabs – tail it, tag it, secure it – and then let us see how many are retained.

Swabs retained in patients’ bodies after surgical procedures are thought to happen from 1 in 500 to 1 in 5000 patients. However, NHSLA data would suggest that it happens much less often (possibly rarer than 1 in 10000 during caesareans). The point is not about the numbers or frequency or other statistics. Firstly, a retained swab is a completely avoidable complication. More importantly, the impact on patients’ lives can be extremely profound when a swab is left behind with infections, difficulty in diagnosis of the complication, re-operation, all sorts of other complications and death.

The impact on the doctor is also serious though not as much as for the patient. It seems that an average surgeon could have a 1 in 3 or 1 in 4 chance of a retained swab happening by his/her hands.

The primary responsibility for all instruments, needles, swabs and in general, anything that happens during a surgical procedure belongs to the operating surgeon. The primary method now used to ensure that a swab is not left in a patient is operator memory, as we all know memory is a fallible method to ensure patient safety. The adjunct to memory is the intra-operative swab notes/notices where the surgeon tells the scrub nurse a swab is placed within a patient, the scrub nurse tells the runner nurse who writes on the theatre white board and at the surgeon tells the scrub nurse when the swab is removed, the scrub nurse tells the runner nurse who removes the note from the board. This six or eight step communication is prone for failure once again because the initiation point is the surgeon’s memory (remembering to mention) and then simply by the number of steps involved in the communication.  

The current next step currently taken is the end of procedure swab count – this happens at the end of the procedure when swabs are counted and confirmed as matching the number of swabs that were opened for use during the procedure. This is actually not a prevention method, this is technically a detection method to confirm that a swab has not been missed, at the best a secondary method of ‘prevention’. 

When a swab count shows a missing swab x-ray is used to detect if a swab is retained within a patient. Surgical swabs these days have a radio-opaque line so that a retained swab can be detected by an on-table x-ray when the swab count detects a missing swab; this is a tertiary or third order issue for detection of a missed or retained swab and does not prevent the swab going missing in the first place. The x-ray method has a known but rare rate of failure in detecting a retained swab.

We know that the current methods are failure prone. The primary prevention methods are memory based – hence fallible under stressful complex conditions.

The swab count, is post-hoc (post procedure), after the event, hence a swab count does not act as prevention, it only acts as a detection method in an area where primary prevention method is highly fallible.

It is known that mechanical methods are better than memory alone. It is best to agree on a single mechanical primary prevention method so as to either enhance the effectiveness of the secondary prevention or to make it a luxurious yet essential redundant detection mechanism.


In the context of retained swabs, surgical swabs during intra-operative use are of two kinds:

Held swab: one that does not leave the surgeons’ (or the assistant’s hand). The swab can be held in two ways a) directly held (surgeons’ hands) b) indirectly held (swab on a stick)

Free swab: is one that is placed within the patient by the surgeon and does not have contact with the surgeons’ hands for any period of time.

A directly held swab has no risk of being left in the patient – by definition a directly held swab does not end up being a retained swab.

An indirectly held swab has a small risk of ending up retained in the patient if the swab slips unnoticed (this is especially possible in the case of pledgets).

A free swab has the highest risk of being retained in the patient. Hence a primary mechanical prevention method is essential for a free swab, irrespective of the swab’s size or the anatomical site of use. Let us look at a method that could prevent a swab from being retained in the first place.


Tail-Tag-Secure is a must for Free Swabs

TAIL: Free swab must always have a tail (taped swabs) which extends outside the wound/incision. This tail could be part of the swab which is extending out of the wound or a formal tail from the swab.

TAG: At the end of the tail which is outside the wound the tail must always have a tag (clip/artery forceps or other instrument holding on it) so that it does not migrate inadvertently into the wound. 

SECURE (the tag): The purist is welcome to secure this tag (clip/artery forceps or other instrument) to the drape as a third level safety procedure, using another instrument. 

TAIL-TAG-SECURE means there is a constant visual reminder about the swab inside the abdomen and a mechanical hindrance to closing the wound acting as a second level safety mechanism. 

The recommendation is that all Free Swabs (any swab that is within a patient and does not have contact with the surgeons’ hand at any point of time), irrespective of the size of the swab or the anatomical site of its use must have a tail (tape), must be tagged (with a clip, artery forceps or other instrument) and most often be secured (to the drape using another instrument or an adhesive sticker). 

This makes the swab count a needed redundancy in the system which is what a detection method should be rather than the surgeons’ memory or a multi-point communication system both of which are potentially highly unreliable as a prevention methods.

A number of surgeons are already using this method. Obviously when these methods are insisted upon, there will be resistance and arguments that may sound valid; however, we know the current method does not work, we know that a retained swab is completely avoidable, we know that a retained swab is designated as a never event. It is time to look for and implement a different and a better solution – the tail-tag-secure is hence essential.

Electronic chip embedded swabs and routine scanning of patients before closure of the wound would be a technology intensive (and possibly costlier) solution. We may be far away, if at all, from completely absorbable swabs. We don’t know if these would have their own problems.

Current Method of primary prevention
Suggested Method of primary prevention
Memory based (fallible): Surgeon’s memory
Visual and Mechanical methods (more reliable)  
Tail (tape) – Tag – Secure the swab

Multi-person Communication based (fallible): Notes on the theatre board

Detection methods (swab counts, x-ray) remain essential
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1 comment:

Vikas Kumar said...

Dear Mr Hemadri
I always read your thought provoking, uptodate, use of technology, management issue realted and even think ahead of time blog.
The only thing how much we can improve the perfection. I do not know we reached the perfection or not. I think at the end it's cost which limit almost every thing. Even in any treatment new instrument even in private, it's all depend on price and who is paying.
Sorry I am just going away from this blog.
How best we can reduce the cost of health care where 65% of expenditure on salary and this is not going to come down if you want real talant and dedicated people.
Yes if tag will be cheaper compare to current practice we all will use.