A SWAB was left inside a patient following surgery because staff were ‘distracted’ by a conversation about time pressures.

Information published by Hampshire Hospitals NHS Foundation Trust (HHFT) which runs Basingstoke, Andover and Winchester hospitals, detailed the ‘serious incident’ which is classed as a ‘never event’.

NHS England describes never events as “serious incidents that are entirely preventable” and have the potential to cause serious harm or death.

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The mistake happened at one of HHFT's hospitals during routine surgery.

HHFT reported that there were distractions during the swab count following surgery, with staff having a discussion about “time pressures on the list and concerns that the list may overrun”.

It added: “A staff member was handing over equipment to the surgeon whilst attempting to complete the count. The competing demands meant they were not able to focus on the count.”

The report said that discrepancies in the swab count were “not acted upon by the team” and added that “documentation was incorrect”.

Hospitals have strict procedures to prevent such mistakes, including checklists and the repeated counting of surgical tools.

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Leaving a swab inside a patient after surgery can require further surgery to remove it, and sometimes such errors are not discovered for weeks, months or years after.

HHFT said in its report of the incident: “This should not occur as all instruments, swabs and sharps must be counted and accounted for and is known as a ‘never event’.”

The trust outlined what had been learned from the incident and blamed a “lack of clear leadership”.

Following the incident, the trust introduced a “whole team focus on minimising distractions during essential swab counts” and launched a ‘pause for gauze’ campaign.

It has also put in place a new ‘human factors champion’ for its theatres who will support staff in escalation and 'human factors training'. 

A spokesperson for HHFT said: “Unfortunately, a serious incident did occur during a routine surgery.

“Whilst we are unable to disclose any further details due to patient confidentiality, incidents such as this are taken extremely seriously. We have a rigorous process in place to immediately investigate, learn and prevent such incidents recurring.

“A number of learnings have already been put in place from this matter.”

Incidents of ‘foreign objects’ left inside patients’ bodies hit a ‘record high’ in 2021/2022 according to an analysis of incidents by PA news agency.

Data showed there were a total of 291 incidents in 2021/22, with swabs and gauzes the most common items left behind, but wire cutters, a part of a scalpel blade, and a bolt from surgical forceps also recorded.

Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: “When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.

“While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventable measures are implemented.”