Ep 8 - HSSIB Retained Sponges Report - Part I

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

Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

Transcript

SPEAKER_01 0:04

When we look at the healthcare system as a whole, of course we're going to see latent conditions that are caused by well-intentioned administrators who are making decisions that really don't necessarily have easy answers to them, who may not even be aware of the issues being caused because until now we didn't have any report of these kinds of things. Now at least we have a real view of what's been going on here and the potential to fix the system. But the system isn't going to be fixed by a simple, well, never do this, practitioner, because that's human focus. The system is going to be fixed by a procurement change at a higher level that changes that latent condition or by a system change, or maybe we use entirely different sponges that are redesigned, that can be multi-purpose, that may actually be cheaper in the end. We always think that, well, to prevent an axe accident, it's going to cost money. Well, have we ever thought that by actually changing sponges, we might actually make the system safer and save money? I mean, we always think of the trade-offs, but it's not always a trade-off.

SPEAKER_00 1:03

Welcome back to the Medical Safety Podcast. I'm Amir Hammond.

SPEAKER_01 1:06

And I'm Adam Shahedo.

The Health Services Safety Investigations Body (HSSIB)

SPEAKER_00 1:08

And the Medical Safety Podcast is a place where we discuss how to improve the safety of our healthcare system through the integration of human factors into system safety, including medical incident investigation and proactive safety measures. In previous episodes, we discussed the UK's Health Services Safety Investigation Body, or the HSSIV, which is an aviation-style body that investigates medical incidents and publishes the findings and recommendations for making the healthcare system safer. In today's episode, we will discuss the HSSIB report retained swabs following invasive procedures published on April 16th, 2024. We'll link a copy of the report uh to the show notes and we'll make sure it's readily available. Um Adam?

SPEAKER_01 1:49

Yeah, so uh in Canada we call surgical swabs sponges, so I think that's how I'm gonna be referring to that. And uh I'm not saying HSSIB the whole time. I'm just gonna call it H Sib. Um and uh that's I think how we'll go with that. Uh Amir, do you want to tell us about the uh reference event?

SPEAKER_00 2:04

Uh yeah, sure. I I can't.

SPEAKER_01 2:06

Should we back up actually and tell tell people a little bit about how these kind of go? Do you want to take it or you want to take it?

SPEAKER_00 2:11

Yes. No, Adam, I think this is all you go for it.

SPEAKER_01 2:14

All right, so let's talk a little bit about the Health Services Safety Investigations Body or H SIB. This is a truly independent as of October of 2023 body in the United Kingdom that looks into medical incidents and they get referred either from patients or family members, sometimes by other actors in the healthcare system. And what they do is, unlike an aviation accident, when we had Martin Bromley on, for example, he said, you know, where aviation bodies typically look at a specific accident and then broaden out from there. So they look at a specific event and then broaden out, broaden out, broaden out. What happens because medical safety is just it's a little bit different. We can't sort of look at just one incident and then look at those one factors and broaden out. They typically have a reference event, and it's basically a patient usually who has been harmed in some way. And then they look at the factors specific to that, but they also tie in a whole bunch of others and they make it about a theme. The theme for this one is retained swabs or retained sponges. And then they look at the factors that go into that. Then they look at perhaps other hospitals, other techniques, and they might also look at other jurisdictions, and then they try and tie it all together with what are the risks, what in aviation we would call causes and contributing factors. And then they would look into what are the possible barriers in place that already exist and how adequate they are or aren't. And then they just look at recommendations. And just like other aviation-style boards, for example, they can only make recommendations. They do not have the power to actually go forward and mandate change. Uh that said, just like with aviation bodies, their recommendations carry significant weight. And we have yet to see, because it's a relatively new board, what the effect will be when these reports come out. But we don't have anything like this in Canada, anything like this in North America. And it really is built on that aviation style. Let's look into this, let's anonymize it, let's publish it so that everyone can learn. And then as we'll see, this isn't just a, well, let's look at this from the lens that we've always looked at this. It's looked at from a system safety perspective. We're going to talk a little bit more about what that means, and how we can do things other than just saying to people, well, do the count better or be more vigilant healthcare practitioners, we can look at how we can redesign the actual system itself to try to prevent these. And what's really interesting is they actually say we should honestly consider whether or not the cost-benefit favors the cost that might go ahead with the redesign of the system. Because when they looked at it, the count is actually pretty good. And so when I say the count, by the way, I'm sure many people don't have a general idea what I mean, but it means that literally nurses generally count the number of sponges that go in and count the number of sponges that come out at particular times, and they reconcile that at the end. This report often refers to the whole process as reconciliation, and then they determine whether or not they need to do things like take an X-ray and so on to see if there may be a retained sponge, et cetera, et cetera. So we're going to tell you more about terminology and so on and so forth. But um, that's pretty much it for how the HSSIB or the H SIB, as I'm going to call it, investigates matters. And we will have the opportunity to speak more to people from the HSSIB down the road. And so if listeners have questions, please feed them into the comments or go to our website and leave us a message. We also have an email, medical safetypodcast at gmail.com, and we'll try and get those questions out to the HSIB. So that's how HSIB runs. Amir, do you want to tell us about the reference event?

SPEAKER_00 5:38

Before we get there, I think I wanted to just clarify a couple of things about the HSIB, just so we're on the same page. This isn't a blame body, right? This isn't a body that goes and looks at specific keys to be like so-and-so made a mistake or so-and-so made an error. The way I conceptualize it, and Adam, correct me if I'm wrong, is I use some inciting incident events to say, hey, is this something that's happening widespread? And even if it's not happening widespread, assuming this is an incident that comes up that is worthy of our attention. What are the big things we can do in future to avoid these? And the the utility of that isn't an audit. It isn't to say that these people met a standard. This is a more of a fact-finding mission to see, hey, if things went wrong, best case scenario, are there still places of error that we can improve on? I I reflect back to the aviation episode that we did for episode two, whereby I was really impressed with the fact that when the uh investigators were looking at the accidents um and for lack of a better term, errors that occurred, what they ended up doing is going through everything step by step with the fine-tooth comb to see if there are any shortcomings that could be better addressed going forward. Obviously, they can't undo the error, obviously they can't hold these people to account. But what the H sub really does is looks at these things from a more critical lens to say, if we have this event in the future or if we have similar events in the future, how could we better prepare for them? What other things can we do going forward? Is that fair to say, Adam?

SPEAKER_01 6:54

It is. And uh as you say, it's not for blame. And they mention this explicitly, both in the enabling legislation and uh in all of their reports. They talk about what their mandate is, that they do not assign civil or criminal liability, that they are not, as you say, for blame. And that doesn't preclude, as Martin Bromley would say, that doesn't preclude people from suing and ultimately getting financial compensation or other things, should that be needed. But just like in aviation investigations, they do this to improve the healthcare system. So we're not here to punish people, judge people, etc., and neither is the HCB. As a matter of fact, their entire mandate is to prevent these things from happening. And so how do they prevent these things from happening? We're gonna see in this report in particular how they talk about how we can not blame individuals, because this is a blame-heavy error that tends to happen. We're gonna talk about things like never events and so on, and the blame often falls to nurses, generally unfairly, in my view, and I believe in the report's view, I think that's fair to say. And the other part to it is blame is not an effective prevention tool. It's not good enough to say, hey, do it better. Hey, be more vigilant now that you know about this. We have to look at the human factors, which include fatigue in this case, potentially, and we have to look at how we can redesign the system, because one of the big takeaways from this investigation is they looked at a hierarchy of intervention effectiveness. In other words, when we look at the system uh and we just say to people, well, you should pay more attention to this, that is not nearly as effective as, hey, what if we redesigned the sponges? What if we made it easier for them to be caught? And then to take it even a step further, the real question then becomes, is it cost effective? Um, and that cost is both in terms of the human cost in terms of harm. How much harm are we really preventing if we were to do this? But also because things come at a cost of a financial cost, the question is, is it from a cost benefit, is it cost effective in terms of OR time if we redesign things? Is it cost-effective from a monetary point of view? And so they really do take this broad safety picture and then they make that into specific recommendations. So yeah, it's a really good point that you start out. I'm so used to the aviation style body. Well, aviation means we don't blame people, but there is still, you'll see the language that many of the practitioners use, there is still a sort of a steeped-in blame culture that we deal with this. And I think if you asked individual practitioners on a day-to-day basis, because just because this report came out doesn't mean we've magically changed the system. These things still occur. I think if you look at this, you'll still see people using very blame-specific language. Please don't think that just because this report came out that magically things are better. No, we have to make the system better, but we also have hard decisions to make at the end of the day. What cost are we going to do? What are we going to do to put this in, and how are we going to implement this?

SPEAKER_00 9:36

So I'd like to go a step further and just highlight what this report was doing and why we chose to describe it. First of all, it's

The reference event: Helen's heart surgery (CABG x 3)

SPEAKER_00 9:45

like the Elaine Bromley case. We don't have a huge trove of these reports that we can go to, although the HZIP does a very good job at compiling them for the UK. I think we chose this report is that it actually illustrates a lot of what Adam and I have been talking about over the past several weeks. It demonstrates the kind of systems-level approach we're interested in. It demonstrates all the cultural things we're interested in. It's very digestible, and it speaks to something Adam and I are both familiar with working in the operating room. We picked this report out of a repository because we thought it was a good representative of the kind of stuff we think we should be having internationally, at least in Canada to start with, uh, that really captures the spirit of what we wanted to get through in this podcast.

SPEAKER_01 10:21

I don't think the public is that interested in having reenactments of surgeries because of the gore and, you know, that sort of thing. But to me, uh, when we hear about Helen, which is the patient in the reference event here, uh, this could have been a Mayday episode, if you ask me. When you look at uh the specific issues uh that happened in this case, and then you broaden it out to the medical system as a whole. I mean, absolutely, this could be Mayday, although most people don't want to be brought into the operating room.

SPEAKER_00 10:49

Okay, fair enough. We've done, I think, enough talking about the age sib and I think we get into the case. So this is a case about Helen who was in her 50s, a middle-aged woman uh who had surgery for coronary artery disease. In fact, she had a coronary artery bypass graph times 3 or triple bypass open heart surgery, uh, which involved opening Helen's chest to expose the heart and took approximately five hours to complete. The day after the procedure, Helen had trouble breathing, and a healthcare provider was concerned that she may have had a pneumothorax or air outside of her lungs between the chest wall and her lungs. It is at least a significant event in the context of cardiac surgery. At 2.30 p.m., a chest x-ray was performed to rule out the pneumothorax. It was documented that the chest x-ray appeared cloudier on the left mid zone in the base of the chest, a partial lung collapse, a huge gastric bubble in the stomach, and no obvious pneumothorax. It wasn't normal, but it didn't have the finding that people were looking for. At 5.30 p.m., another chest x-ray was taken and an opaque object was identified in her chest. The chest x-ray was discussed with the cardiac surgeon and there was a concern of a retained sponge. Another chest x-ray was completed at 7 p.m. and it confirmed a retained sponge. The plan was to go to the OR the following day to remove the sponge. Helen deteriorated overnight and she was in respiratory distress and she needed to be re-intubated. The next day she went to the OR and the sponge was removed. During the operation, Helen's O2CAT was not reassuring. It did not go above 87%. She was hemodynamically unstable and quite sick. Given her precarious position, the decision was made not to x-ray her chest intraoperatively to confirm the sponge removal. They decided to close the chest and bring her to the ICU for uh hopefully to stabilize her and prevent any further deterioration. A chest x-ray in the ICU later that night was performed, and they saw a second sponge in the same location as the first. Following morning, she went back to the operating room for a third time to remove the sponge or swab from her chest. A chest x ray was performed this time in the operating room that showed no foreign objects present in her cavity before they closed. Helen was in the ICU for seven days and was discharged 13 days after her final surgery to remove the second sponge. At home, Helen had ongoing health problems and a difficult recovery. Helen's family actually brought up this case to the HCB. An investigation was started to identify factors associated with the unintentional retention of foreign bodies. This does not include vaginal swabs or sponges, which was the subject of a separate and earlier investigation. With Helen's event, the goal was to identify alternative safety controls to reduce the risk of these events happening in the future. When the investigators first met Helen six months after the incident, she was visibly upset by what had happened, understandably so, and she reported that she'd received limited mental health support. Uh, and according to the report, Helen continues to have health and uh well-being issues from this.

SPEAKER_01 13:40

So, Amir, just before we move on to the actual investigation itself, I just want to highlight something that you've said many times on this podcast, which is to remember that the patients that we care for are people with full lives and loved ones. I really think it's important that the HSIP use a reference event like this, and they use the first name of the person affected to bring to life the issues that we're talking about. It's not just a here's this month's theme that the HCP is investigating, you know. And so I really wanted to identify that. And you can see here that this woman who had her chest cracked three times, twice unnecessarily, or at least potentially preventably, we'll see whether that was realistically preventable or not. And I just think it's really important that we talk about retained sponges, and yet we see this, you know, very vivid idea of what's happened. And they even went so far as to say, here's the after effect. We saw them months later, and they were still upset by this and had downstream health consequences, sequelae from this, and then they were able to offer her some additional uh support and so on. And so we really do see the harm that's come from this event, uh, which really does bring it to life. What do you think, Amir?

SPEAKER_00 14:47

Yeah, I I really like that point, Adam. Like at the end of the day, these are people, and what's it saying one death is a tragedy and a million deaths is a statistic. It's not to discredit the million deaths that have happened, it's just using this one particular example to really hammer home the message.

SPEAKER_01 15:00

Um

The background and context of the report

SPEAKER_01 15:02

because in an alternative world, they could have just said, well, here's this month's report, and we're looking into this this month. Here's the sort of flavor of the week, so to speak, and this is a very different kind of report to their credit, I think.

SPEAKER_00 15:14

I know we're gonna talk about this later on, but the theme of retained sponges and swabs, why it's so important. Although this is probably not a very frequent event in the grand scheme of healthcare interactions, A, it's probably more frequent than we initially think. B, it can have serious consequences as we see in Helen's case, and Helen's case is not an isolated incident. And finally, thirdly, I think it captures a lot of the potential pitfalls that occur in routine surgical procedures in the operating room and does a really good job at highlighting where potential errors may occur, where the flaws in our system are. So I think that's why this event, and particularly this theme of events that they encapsulated in this report, is important for us healthcare practitioners, particularly those working in the operating room, to be aware of.

SPEAKER_01 15:57

Okay, we're gonna dig into the investigation itself, and we're gonna start with the background and context. So this investigation began September 28th, 2022, and just like they sometimes do in aviation reports, they had enough information that they actually published an interim report December 7th of 2023, which was 14 months later. And that interim report highlighted common themes in 31 serious incident reports, those investigations that had been carried out by local healthcare trusts. And a trust, just because it's not a term that we use in Canada, is a sort of a local body in the UK. It might be one hospital, but it's a board, if you will. And sometimes the trusts will have responsibility for more than one hospital. So it's sort of a local region of a hospital or several hospitals that are there. So just think when you hear trust, just think of a local board, if you will. And so that interim report came out December 7th of 2023, and the final report itself came out April 16th, 2024. And so when we consider this alongside other safety critical industries, we'll see that these investigations are in-depth. They talk to a number of different people, they gather evidence, they look at human factors design of whatever the equipment happens to be, as well as the people, and they really dig into the issue, and it can take a good couple years for this to actually come out. And I think that's completely fair because the last thing anyone wants is to have sort of a gloss of safety, sort of safety theater, where you sort of look into something for six months and then come out with a very superficial report, and then you say, Well, we looked into it. It's almost like a whitewashing. No. It was a report that was clearly in depth, where they had meaningful review of not just the specific incident, but the themes that were brought out in these 31 other serious incident reports. And then they did an actual analysis of the human factors involved that day, of the processes involved, of the equipment involved, of the various organizations in order to try and say, what can we meaningfully do to fix this system? So they have a background and context section in this report where the HCP begins by setting out the scope of the investigation, what they're there to look into and what they're not looking into, and then the risks of retained sponges, the fact that they talk specifically about patient distress, infection, possible death. And of course, we can see that in Helen's case specifically, but they do highlight this. What are we really talking about here?

"Never Events"

SPEAKER_01 18:12

They then also detail what a swab is, which they define as pieces of gauze which are used to absorb bodily fluids such as blood during an invasive procedure. Um, if you worked in an OR, you've seen these things. They're literally just looks like cloths that are can be various sizes. They typically have uh a blue stripe, at least the ones that we use in Canada, typically have a blue stripe or some kind of strip on there, which does a number of things, and you will see later on that one of those things is there are radioopaque threads so that when you take an x-ray you can actually see them, because otherwise, as anyone who's taken an x-ray before with clothing on, you don't see the clothing in the x-ray. We have to put something in these sponges so that when we take an x-ray, we might actually be able to see them. And so they're gonna look at the design of them. So after they define sponges, they talk about never events. So the NHS defines events 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. And so we, almost like a lawyer, have to look into this and say, are these really truly never events? And there's a whole list of them. I won't go into all of them, but unintentional retained sponges are considered a never event. And there's a lot of discussion in this report about whether we should even have the term never event. And then they also look into this and other reports, many other reports, including a 2018 NHS improvement report. So we're going back several years and there have been other reports, really look at these events and say, well, can we really say they're never events? Can we really say that they're wholly preventable? Can we truly say that we have strong systemic barriers? And as we will see later in this report, there are a number of these reports, including this one, this retained sponges by the HSIP report, that call for never events to be renamed. And they call for this because the events that are described are not entirely preventable, and there are not strong barriers available to prevent them, meaning that much of the barrier relies on the vigilance of staff. And when we look at the hierarchy of uh effective interventions, that is not a strong barrier. That is a barrier, but it's not necessarily a strong barrier. And then B, by calling them never events, it invites stigma and shame and discourages reporting and discourages a thorough investigation. The reaction, the knee-direct reaction is well, do it better, healthcare practitioner. So we're gonna come back to the idea of renaming never events as it plays a role in HZIP recommendations. Uh, Amir, I can tell you you got something you want to you want to come in.

SPEAKER_00 20:35

Absolutely, yeah. I think it's helpful to frame why we're talking about never events in this context. I think it's very helpful, like you said, Adam, to like really grasp the full pictures to what happens when we have these quote unquote never event events happening. What we're supposed to do, I think, what the healthcare regulators would say is like, hey, when we have a never event, we have to stop and like look into all the findings and understand why this happened. What I think the use of the language of never events, what it implies is that these are such singular events that we can find one identifiable cause and go back and say, when we find this cause, we will never have this never event happening again. What I think the H sub report does, and what I think Adam is trying to highlight, is that really actually undervalues all the factors that go into play for a quote unquote never event to happen. There are very few true never events that happen. And so framing them in the context of never events, A, might put undue blame on individuals, B might stop us from analyzing the bigger systems at play, and C might actually have a disservice when we investigate these things. We should not just be investigating never events when they happen. We probably should be looking at all the events that are either near misses or don't fall into this category neatly. If I could point out an example, I'm sure we've all heard stories about surgeons operating on the wrong leg or amputating a wrong body part or putting something in where they shouldn't have. And yes, we like to say. Well, that should never happen. But when we frame it in that language, what we fail to recognize is all the systemic factors that might have led to that. Perhaps the surgeon was operating in the middle of the night on call when they were tired and fatigued. Perhaps they were doing this at the end of a busy day or at the beginning of a day where they had a lot of time pressures. Perhaps the people in the OR felt unempowered to speak up. Perhaps there was a change in equipment supplier that changed the labeling that wasn't really quite clear. And so I use these examples to demonstrate that obviously all these never events are regrettable and in a perfect world should not happen. But frame them in that context that their systemic factors at play acknowledges that they will happen and furthermore gives us a sense of vigilance so that we're always aware that any event could potentially be a never event, and we always have to stay on the lookout for them. I just wanted to get that point across. I hope it was clear.

SPEAKER_01 22:47

I think there are three things that that you're really highlighting here, and the HSIP is doing the same thing in a similar manner. The first is the idea that are these actually never events? Like when you look at the definition, wholly preventable, and you said they may not be, and we'll look at how retained sponges may not be wholly preventable. And then, of course, strong systemic barriers to protect against. So we've talked about how that isn't the case here, and the HSIP looks at that as well. The second thing that they look at is the idea of how helpful is the language? Like any intervention, the language that we use can be helpful and cannot be helpful. And so in this case, you talked about how the language that we use is very blame-centric. Oh, that never event happened, that should have never happened, therefore you guys must have done something wrong. And it really discourages, as we talked about reporting and so on. And then the third thing is, and the HT really gets into this, how does the public perceive risk? And what are we going to look at? And we'll see that I think at an academic level, many of the practitioners would say, yes, we're willing to embrace any kind of language and any kind of process that might actually reduce risk or encourage reporting and so on, with a view to reducing risk down the line. However, if we take this language away, is the public going to think that this might happen to them when they go into the OR? Right. And that's a big concern, is how does the public perceive the safety of the healthcare system? And of course, that's a reality that we have to consider when we look at safety systems. The HSIB makes it very clear that we're never going to get risk down to zero. And so we have to acknowledge that and then say, well, we have to reduce risk to an acceptable level. And that's that's uh that's scary for a lot of people because we're all patients at one point. Perfect, perfect. Okay.

SPEAKER_00 24:21

I don't want to take credit for anything that was said in the report. I just want to clarify and provide more context and more detail to make sure that these.

SPEAKER_01 24:27

I think that that's why we're here. That we're clinicians, we we work in the operating rooms and emergency departments every day, right? So I think it's totally fair, you know.

"The count" or "reconciliation"

SPEAKER_01 24:34

Much of this report focuses on the count, which is also called reconciliation. And the count is sponges, surgical swabs, are counted in a very specific way by two trained nurses who must agree on the count before the sponges are actually used. And in fact, in many places, they'll actually sign with their signature a paper that says that they have counted, right? And so and this has been this way over it's developed over years. It's something that is taken incredibly seriously by nurses, as it should be. And that's what we focus on. So the count is done at the start of the procedure before when everything is laid out. And remember, this is these are sterile sponges, so they have to be done in a particular way, and how the how the sponges are shown to the other circulating nurse. So you have two nurses. You have a scrub nurse who is scrubbed in and sterile and has a gown and has sterile gloves and everything on, and you have a circulating nurse who will come and hand things in a sterile fashion up to the surgical field if it's needed, or up to the scrub nurse, I should say. So the circulating nurse is the one around in the operating room that is non-sterile, that can go into the corridor and grab new equipment and bring it in as it's needed. Okay. And then of course the sterile people are the surgeons, the surgical assists, the scrub nurse, right? So at the start of the procedure, before the procedure starts, the scrub nurse and the circulating nurse count, and then they do another count before the closure of a cavity, and then before the first layer of muscle is closed, and then before the wound itself is closed. And then the final count is is performed at the beginning of closing skin. So there are different layers of fascia and skin and so on, and then the final count is performed at the beginning of closing skin or before the end of the procedure, depending on the type of procedure. So you can see that all of the things that are up, including the various parts, so sometimes equipment has more than one part, and that is counted. And so this is done in a meticulous way, and it's done multiple times.

Standard Operating Procedure (SOPs) in medicine

SPEAKER_00 26:20

The idea of this count is to prevent any retained products. It's to make sure that when we go and finish the surgery, we have not left any piece of equipment in the patient. Everything is accounted for. We don't have to go fish around for things. The idea is as as the surgery progresses, there is a very, very, as Adam said, meticulous, but I would say thorough accounting of all the things that go into patient bodies and all the things that come out of patient bodies. So again, for those who are not very familiar with the OR, every time a new piece of equipment is ordered or opened in the surgery, even if unanticipated, there is a thorough accounting of it on all the sheets. Everyone who's ever worked in an operating theater to some extent realizes how important the count is. Realize that people are very, very particular with the count. They don't let other people come in and disturb their account, they don't leave the surgery before the count is done. And the reason why is we want to prevent these events that happen to Helen. The reason the report focuses on the count so much is that I think, like the checklist that we will inevitably talk about in a future episode, we have built these up as a fail safe up here.

SPEAKER_01 27:31

I did not have a true appreciation of how seriously the nurses took the count until I think I was working a good couple years in there, until I saw some emergency cases, until I saw some nurses say, the count is off. We're not doing anything until we fix the count and figure out whether there's something that's left behind in this patient. It is taken incredibly seriously because, as Amir said, it's the primary method of actually finding these things. And I didn't actually appreciate this until later, when we don't have time to count because it's a true emergency. They don't count, they do the surgery, and then they take x-rays afterwards to rule out retained equipment and so on. Sorry, Amir, go ahead.

SPEAKER_00 28:08

I was gonna say, unfortunately, this is one of those things that's built on the blood of patients, right? Like the count has been so thoroughly established because patients have died from retained products. We were like, oh, did we see these? Did we count them? No, it looks all good. We put all the things away. How could you leave something? We looked at the surgical field, etc., etc. The count is made uh and designed intentionally so that when you have surgeries, when people aren't at their best, when people don't have maximal vigilance, when we start packing things like gauze and instruments away in different parts of the cavity that we might not immediately be able to see, we can keep track of those, even if they're not in our immediate visual field. This is to prevent multiple operating room takebacks. And before that, or I should say in addition to that, preventing patients from getting quite sick and dying from things that we could really, really easily do. This is a form of checklist or safety.

SPEAKER_01 28:52

So in my mind, this is this closest that medicine gets to what in the aviation world we would call standard operating procedure, meaning the standard call-outs that we get. Because there is a very particular way that they verbalize the count, that they physically hold the things when they're counting them, because you have to do it in the same way. You have to be able to work with somebody else who you may have never worked with before. And you have to be able to do it the right way, a way that is safe, and that is standard operating procedure, right? So in the aircraft, for example, you have standard call-outs, you know, you have V1, rotate, etc., all these things, bank angle, airspeed, how you run the checklist. Those that's all considered standard operating procedure. And that's how you physically work in a cockpit, that's how you verbalize your actions in the cockpit. And I would say that's the same thing that we have here in medicine. It is identical to what we would call standard operating procedure. But standard operating procedure is something that you train on in both medicine and aviation. And it's also subject to oversight and criticism if we ever get to that point, at least in medicine, where there are people who adhere more closely to standard operating procedure, both in the cockpit and the OR, and we're gonna see that plays a role later on.

SPEAKER_00 30:01

I know

SOPs and knowing other team members' roles as CRM in the OR

SPEAKER_00 30:02

you said this, Adam, but I just want to underline, highlight, emphasize this point. This isn't just a count that random people in the OR do. There's training, there's protocol, there's procedure to it. Like I cannot do a surgical count, uh, nor should I, because I don't know how it's done. Uh and so what what I I bring this up just to say this isn't just some whole hum thing, can you count to five, right? It is a meticulous and uh organized and trainable and with standards, right?

SPEAKER_01 30:28

With standards associated with standards procedure that I don't know, and as you said, you don't know. And I that comes to play later on because we'll see that surgeons are ultimately responsible for the count. But just as I don't know physically how to do the count, neither does the surgeon, right? And so surgeons are responsible, and we'll see that the HCB later on says, Well, surgeon, in some documentation, according to UK healthcare policies or hospital policies, you are responsible as the surgeon for the overall surgery because you did the invasive procedure. And the surgeon, and in uh in another documentation, the the scrub nurse and the nurses are responsible for the count and so on. And the surgeon will say, Well, I'm the surgeon, I'm overall responsible for the surgery. But you have to understand when I'm closing, when I'm closing the layers of fascia and skin and so on, I'm working on the patient. I'm not actually paying attention to how physically the count is going on. That's not something that is in my role. And so I have the responsibility, but I don't have the physical capability, nor do I have the training, which is something that comes up later on, right? I don't know any surgeon that gets trained or he's even ever shown how nurses actually count. And it is worth considering, both for myself as an anaesthetist and surgeons and so on, whether or not some of that cross-training should take place that the HCP then comments on. If this cross-training were there, a few things might happen, right? One is perhaps surgeons, as we'll see later on, might have a little bit more respect for the count. And most surgeons that I that I deal with do, but as we'll see later on, never say never, and not every surgeon has that appreciation. And there's a lot of blame that gets thrown around. And so the general rule in any safety critical industry is when we know how other people work, how their actual workflow happens, we are better able to cross-check and monitor, and then we have a little bit more respect for the role that they provide, and then we perhaps might take their comments and feedback a little bit more seriously. And so when we talk about CRM and team performance, that's part of what goes into it. Do we know what the other person actually does? Do we know how they physically perform the work and the importance of it and how seriously they take it and why they take it so seriously and so on? So we're gonna take a quick break, and when we come back, we're gonna talk about the HCB's analysis and findings regarding the specific reference event. And we're back.

The analysis and findings for the reference event (Helen’s CABG)

SPEAKER_01 32:35

We're gonna look at the analysis and findings that the HCP had for the reference event. This was Helen's case specifically. And the first thing that the HSIP noted in this report was that, quote, 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. Very few notes were made in Helen's medical record during the procedure, so the investigation relied on staff recall of events. To gather more information about how swab reconciliation works in practice, the investigation observed a coronary artery bypass graft, sometimes referred to as a cabbage, and a lobectomy. This is where they resect a lobe of the lung, a part of the lung. In my mind, it's 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. And yet, in the entire report, which spans many pages as you would imagine, there is no mention of recording devices. And in aviation, when airplanes crashed in the 50s and 60s, they had to invent a robust means of recording what occurred in order to determine what happened and how to prevent future accidents. And of course, we're talking about aviation black boxes, the cockpit voice recorders and flight data recorders. And these needed to be able to withstand fire and immense G forces when airplanes crashed, and to be able to survive underwater and immense pressure and have sonars so that they could be found when they're in the ocean. Offering limbs don't do those things. And so for me, I don't understand why, you know, we don't have even a mention here of, well, maybe we should audio video record just like we do in aviation, and that would provide the evidence that was needed almost certainly to find out what happened to Helen. But also it would have provided so much more rich information that the HSIB would then have access to in order to actually look at what goes on later on. So you'll see that another limitation of the investigation is not just for the specific event for Helen, but also that there may be things in the culture, in the manner in which operating rooms were running that they didn't capture because again, they're relying on notes and they're relying on recall. And frankly, that's just such a poor level or quality of evidence that I can't understand. My main criticism of this report is that they did not mention black boxes. They didn't even mention the possibility of black boxes. I can understand them saying we're not ready for it, maybe we need legislation, et cetera, et cetera. But to come out with their first finding and say, well, the evidence was limited and therefore we couldn't find it out, let's move on to another way of investigating, really sort of runs afoul of their whole idea of coming from let's look at what happened in other industries and maybe we can bring those same concepts in there. So that was my main issue there. We're gonna look at what the investigation found in terms of the factors. We're gonna look at four things that they looked at. The first are factors affecting the sponge count itself. The second are factors affecting the detectability of the sponges in Helen's chest, in other words, during the operating room itself, why they're why they weren't found. Okay. The third are why the factors weren't found on the chest x-ray. And the fourth are factors that affect the detection of that second retained sponge. So they take them in order in that way, and that's how we're gonna take them as well, Amir.

SPEAKER_00 35:30

Yeah, again, point of clarification, just because as Adam is speaking, it's helping me conceptualize the report that was written. So I I I think what stands out is the HZIP came into this to be like, hey, how did this happen? It's not clear, just looking at what the OR record is, it's not clear talking to people how this event actually happened. So the first thing they did, and I'm just rehashing Adam's words, and I'm just rehashing what the report is, they went to actually look at one of these surgeries, but are these surgeries inherently error-pro like what is going on? Which I think is a really useful tool. They stepped into the room that these things were done, and they said, Do we actually have an understanding of the lay of land? And after that, like we we have a general sense. So now these are the areas that we've identified as being key areas of concern.

SPEAKER_01 36:11

I will I will also say, this is just a very quick aside, that at no point was the consideration, well, the individual practitioners were sloppy, right? They looked at another surgery so that they could say, well, these are professionals, and they've been doing surgery, open heart surgery successfully for decades. And so really it was a question of let's look at the standards that we have so that we can then go there. I think it's really important that the age sips started from the point of these are professionals who were well-intentioned and caring people, and and they meticulously perform high-risk activities every day, and most of the time they get it right. So let's look at these other surgeries so that we can then say, how can we do even better?

SPEAKER_00 36:53

Totally. And the four factors that Adam brings up in the report highlights are the four areas where the count would have been affected. That could have been an area that impacted our ability to retreat sponge. They essentially highlighted four themes that are common to show that, hey, we got to look into these a bit more closely.

SPEAKER_01 37:08

I suspect, although they don't say this explicitly in the actual report, I suspect when you look at those four factors that those were the four times or barriers that were in place that could have prevented the unintentional retention of the sponge. So the first barrier was the count. And that obviously was not a sufficient barrier, as James Reason would say, there was a hole in that barrier, and we're gonna look at they're gonna look at the factors that affected that hole, if you will. The second barrier was the surgeon or the people in the sterile field that were looking in Helen's chest, okay, and why that wasn't an appropriate barrier or why that barrier failed. And they're gonna look at that. The third barrier was the chest x-ray, and that was another opportunity for the sponge to be identified even on that first chest x-ray. And so why didn't they? Why did that barrier fail, in other words? Not why did the people fail, but why did that barrier fail, right? The fourth barrier was the second sponge was left in when the surgery took place to remove the first sponge. And so they're gonna look at all those factors. And so if we look broadly, those are the four big barriers that failed. And so when we look at this from a Swiss cheese model, they're gonna look at this and say, how can we, first of all, how can we make the existing barriers better? But then they're also to use the Swiss cheese model language again, they're gonna say, Well, what other barriers can we put into place? And that's when they start to look at this hierarchy of effective interventions.

SPEAKER_00 38:35

All right, let's continue. Adam?

SPEAKER_01 38:40

So

Factors affecting the count

SPEAKER_01 38:41

we're gonna put some of these factors and subfactors uh into the show notes because it's just gonna be easier to look at from a list perspective. And so I'm just gonna talk about what the interim report talked about because that's how they structured the final report. They said we're gonna we're not gonna repeat ourselves into what went into the interim report. So I'm gonna quickly talk about some of those things in there. Uh, but honestly, if you're having trouble following what I'm saying, you can just look at the show notes. So uh in the interim report, it notes that in most reports, these are reports of local investigations, surgical swab counts had been perceived to be correct when they were not. So that's the first thing to identify is the idea that the count is not as uh reliable as we often think that it is, right? So as they say, this finding indicates that the current practice of encouraging two people to complete a swab count is not a reliable barrier to prevent the retention of swabs. And so this turns back to the idea of well, should we really call this an ever event when there isn't that strong systemic protection because the count as being human-focused, people focused, is not a strong barrier. So let's turn to the first factor, and that was those factors that affect the sponge count, okay? And we'll look at the responsibility, so who has responsibility? We talked about the fact that uh surgeons in some cases, scrub nurses in other cases, and they really looked at this, you know, who has responsibility. The second one was let's look at communication around the sponges. And this is the idea that when a sponge goes into a cavity, the first of all, the surgeon will call for a sponge, the scrub nurse will hand a sponge to the surgeon, the surgeon will insert it into the cavity, and usually they are required to announce it, kind of like a standard operating procedure, like a call-out in aviation, sponge in, et cetera, et cetera. However, due to the nature of surgery and due to the procedures in place, it was noted that surgeons are not sometimes it was noted that sometimes surgeons are not informing the scrub nurse when a sponge is inserted. And this might be because they're controlling critical bleeding, etc. There may not be so-and-so time, et cetera, right? But the adherence to that standard operating procedure isn't perfect. Then there's the other idea that inserted sponges aren't always being recorded on a count board. This is not something a mere that I've seen in Canada, but in the UK they have a board that they have that counts literally uh the number of people. And this would be the circulating nurse that'd be doing this. Have you ever seen this in Canada? I have not, no. No, I haven't had either. So there's this idea that there's a count board and it's not always being updated and so on. And in my mind, part of this is perhaps there isn't even the concept of a readback, hearback that we see in aviation, not just in radio communication, but if I'm calling, you know, bank angle and the captain, for example, is uh, you know, saying correcting, I say, you know, check or roger or something. And that's the idea that there are these specific call-outs. We could have that in medicine. We just don't necessarily have that, where a surgeon could say sponge in, and the nurse could say sponge in or check or something like that. And when we look at different ORs, so I've been in cardiac ORs, for example, and the readback that is done between the perfusionist, which is a different role, and the surgeon is often excellent. Um, and we see that with x-ray technicians, for example, we see that with other people who have these safety critical parts. And perhaps because of the nature of surgery, they just don't have this necessarily in medicine. But in my mind, that could be a barrier that could be strengthened. But as we'll see later on, that's again human-focused and perhaps not the strongest, but it is still something that could happen, right? Another thing that the HCP found about communication was that some nurses did report that they were ignored when uh they were talking about the fact that the count was off and they just were ignored. And so some trusts actually implemented assertiveness training or terminology such as, quote, stop, I have a concern, end quote, to empower those nurses. And in the reports, there was evidence that these new practices weren't always necessarily being used or that the surgeon was ignoring them and so on. And there's a quote here, the scrub nurse repeated this several times, asking for everything to stop whilst the count was performed again, and an attempt made to locate the swab, no verbal recognition of the information given to the surgical team was made. And we've seen this before in other cases where nurses are being ignored. And I just want to highlight that there is a power imbalance there, obviously. Okay, let's talk about visibility of swabs. These swabs are not always in direct line of sight, so they can be behind organs. They can also be soaked with blood, and therefore, when a white sponge absorbs blood, it begins to look like the surrounding tissue. Also, radioopaque stripes, these are the blue stripes on most of the ones in Canada, appear similar to other lines on an X-ray and an X-ray is performed. We're going to look at this later on. The makeup of the operating theater was another factor. This meant that nurses are changing out, the count isn't always being conducted between the same nurses, the count isn't always being conducted between outgoing and incoming nurses, and so on. Then there's the timing of the count and its confirmation at sign out. This is the WHO safe surgical checklist where we have sign in before the when the patient gets in the room, then we have before skin incision, and then we have sign out, which is upon closing. In some cases, the skin had already been closed when the final count was performed, and they lacked clear communication, or the surgeon had just assumed that since they had been handed the instruments by the scrub nurse to close, that the count must be correct, because why would they be handed the instruments otherwise? And these are just some of the factors that went into it. The type and duration of surgery was looked at, and it was most commonly found in laparotomy for these unintentionally retained sponges. This is abdominal surgery, and in surgeries lasting more than four hours or quick surgeries lasting four. Less than one hour. Then they looked at the culture, and they said that sometimes surgeons are taking sponges directly from the nurse's table without informing the nurse that's a violation of protocol. Consultant surgeons would sometimes leave the OR letting junior surgical members of the team close. They looked at distractions and interruptions. They looked at competing tasks such as counting while doing other tasks. They looked at the time of the day. They looked at time pressure. They looked at the clarity of various policies. Again, there is this identification by the HCIB of weaknesses in the level and quality of evidence available, and this idea that OR black boxes could potentially have improved that level of evidence. And then the final report, not the interim report, but the final report, conducted an in-depth hierarchical task analysis. And this is a flow chart that if you go to the link that we'll provide in the show notes of the actual report, it's quite, quite detailed. I'll be honest, I have difficulty following it. It looks at a hierarchy of key goals and subgoals and actions and plans regarding the count itself. But this is all to say that they did a very in-depth investigation, and the investigators noted things such as the scrub and circulating nurses being required to count 235 different items for a coronary artery bypass craft, or in some cases there being over 200 needles and over 50 sponges. It just gives you a sense of the immensity of the task. It should be noted that the cardiac OR is not like other ORs. It's noted to be intense and busy, and there were critical stages of the surgery for this particular type of surgery. It's not like, for example, taking a gallbladder out. It's just a very different kind of surgery with a very different sense in there. At quieter times in the procedure, the scrub nurse was noted to, as is standard, removing sponges from the field. These are soaked sponges, and that limits the number of sponges in the field. And the scrub nurse puts them in bags five at a time and they were crossed off on the count board that they use in the UK. Once they're in the bag, however, it's difficult to see how many there are, right? There might be doubled up because they might be sticky with blood, etc. And according to the policy, those are not re-counted again unless there's a discrepancy in the count. The integrity of the count then relies on each individual count being accurate when these sponges are removed. And if an error in the count coincided with an unintended sponge retention, it would not be identified by the count. And then it says given the various locations of the sponges, clean sponges on the scrub table, partially used sponges on top of the patient, used sponges in the patient, there is a risk that sponges can be accounted twice or incorrectly. And then finally, while the surgeon remains overall responsible for the count, we talked about the fact that they are generally not involved in the actual count itself. Amir, looking back on these factors, are you surprised by any of the findings so far? I mean, we both work in the OR most days, so I wonder how much of this we just tacitly accept because that's how it's always been.

SPEAKER_00 46:40

I'm I'm honestly not surprised, Adam. Like I I hear this.

SPEAKER_01 46:44

Yeah, I wasn't surprised by any of them. I think the surprises for me come later on when we look at the bigger factors. I will say the overall theme, the overall brush is, I mean, we think of the count as sacred, and it's just not as reliable as we thought. I mean, it works most of the time as we're gonna see. But yeah, okay. I mean, of course nurses are distracted and doing multiple things and so on. I was a little surprised to find that there were surgeons who just kind of steamrolled over nurses and things like that. But you and I have have, you know, have seen similar things per perhaps before. So it shouldn't be a surprise that uh it does sometimes happen.

SPEAKER_00 47:17

Uh I think what reading this part of the report did for me is it reinforced that what happens in the OR and broadly speaking, medicine in general, may seem straightforward, may seem very obvious. Like how hard is it to actually count something that is oftentimes packaged in sets of five or ten. But it really reinforces the idea that this isn't happening in a vacuum. This is happening when there are many other things going on at the same time. And so back to our CRM discussion in terms of cognitive load, in terms of computing priorities, in terms of clear communication, there can be many factors at play that shrink our cognitive capacity to do these things that are actually vitally important, right? We're in a very dynamic environment. You and I have been in cases where the surgical field is changing drastically, and early identification, early management of a bleed, a complication, or whatever can save us a lot of time. So we may not have the luxury of sitting there and giving another 30, 40 seconds for the count. That may in fact be too long. We've also been in rooms where the phone is ringing, people are coming in and out, and you can be interrupted between your count at any point in time. And yes, counting from one to five should in theory be simple, but as you mentioned before, our sponges are white, and sometimes the contrast is not super clear. Sometimes they stick together. Sometimes the packaging itself isn't exactly perfect, and so you have to troubleshoot all these things on the fly while you're doing this highly mentally demanding cognitive task of both counting, which is in and of itself not easy. But secondly, the people who are designated to count are also helping with other parts of the operating room. We don't just have two people in the corner counting things all day, every day, right? These are often the people assisting directly in the surgical field, are oftentimes mitigating things outside of the operating room. So you're pulled in these, like what I encourage the people who are listening and very interested in this to get the point of really how hard are these things, is actually to look at that hierarchical task analysis. You don't have to understand it. This is not a test, we're not testing you on it. But if you look at how complicated these things are, if you look at all the factors that go into making count efficient and correct, there are many, many, many, many, many of them. And seeing it all laid out over the course of like several pages on my screen where I had to like zoom in a billion times to read each box really reinforces the idea that things are not as simple as they may seem. And we do a very good job in medicine at training people to do the task in ideal conditions, and we hope that with time and experience they will do them in suboptimal conditions. But the reality is these are tasks that are cognitively demanding and complicated and have real stakes when we get them wrong. So I just wanted to hammer home the point that this isn't surprising. Once they're delineated like this, you're like, yes, obviously all these things impact the count, all these things impact the things in the OR. These things do not happen in routine cases where we're fixing something very simple, like a little laceration on the skin. When we need the count to be super, super precise is when we're doing big deal surgeries or when patients are in distress. And that is exactly the time where we have a lot of distractions. That is exactly the time when pa people are coming in and out of the room. That is exactly the time there's a lot of noise in the OR. That is exactly the time where the nurses or the scrubbed people are being pulled in many different directions. We are essentially fabricating the perfect storm for the count to go wrong exactly when we need it to go right.

SPEAKER_01 50:15

I think you hit it right on the head there. What I was gonna say was this is a situation that the sum is greater than the parts. And I think if you, as you say, if you look at this, that's not a surprise to people that work in the OR overall. But I think conceptually, when those of us who work in the OR think of the count, we think of, oh yeah, well, we're setting up for an elective case and the course of the nurse is gonna count with stuff. And as we saw both in real life, but also in the report, no, that's just not the way the work is actually performed. It's often done in trying conditions, in adverse conditions at 2 a.m. with multiple distractions, etc. That's the first thing. The second thing I will say is you and I work in the situation quite frequently, but it's really nice that we get with this report an outsider's view where yes, they're clinically educated, but you come in and you kind of go, well, if you were designing a system from scratch today, is this how you would do it? Right. And I think that's part of what the HSIP kind of looks at. If you look at MASH or any of these older TV shows or anything like that, MASH was filmed in the 70s, but it was about the Korean War in the 50s. I mean, we've been doing this this way for about a hundred years, and yet our technology has evolved immensely. And if

Patreon Extended Version

SPEAKER_01 51:16

you've enjoyed this conversation, we've actually got another 30 minutes of our discussion about the HSIBs sponges report that's available exclusively on Patreon. For just five Canadian dollars a month, you'll get access to the extended version while helping keep the medical safety podcast going. We don't receive any outside funding, so your support goes directly toward producing future episodes. In this exclusive conversation, we discuss factors affecting the detectability of the sponges in Helen's chest. We also discuss factors affecting the detectability of sponges on X-ray, and factors affecting detection of the second retained sponge. We look at SOPs and call-outs by surgeons, and there's quite an interesting discussion between Amir and I about OR black boxes and medical culture. All of that is in the extended version that is available on Patreon. You can find the link to our Patreon in the show notes or just go to patreon.com slash medical safety podcast. Thanks for helping us keep these important conversations going. And

Systemic vs local investigations (HSSIB vs M&M)

SPEAKER_01 52:12

now back to the rest of our free content. You know, Amir, I'm quite impressed with the depth of investigation and the level of analysis. We've talked about it a couple times now that a lot of this information may be tacitly accepted, but in the context of practitioners at the front end with only so many tools, we really would never have gotten a view of how the working conditions are in context to other types of operating rooms, how the procurement would have an effect on this. And so I'm really impressed that it seems true to the origins of aviation acts investigation that we've spoken of in the past. And we talked about how in other investigations they're not just satisfied with finding the approximate cause. They're going to look at as much as they can so that they can improve all aspects of the system, whether or not they necessarily played a role in that specific accident. And so they didn't just look for why was that sponge left in in Helen. They asked at several parts why the sponges weren't identified on the chest x-ray, in that second OR, etc. And then they looked at the culture of medicine in terms of changing the count. And then they really sought to understand, well, why did the count develop in the way it did? And why haven't better solutions come up to date? So in that way, they're really trying to ensure that any recommendations that they provide are likely to be acted upon, rather than necessarily being seen as, well, that's just an ivory tower thought process, these people don't know what they're talking about, they're not clinically educated, or just generally being disconnected from how the work is really done. I have to say I'm really quite impressed that it seems that this was a real endeavor to have a meaningful review. Again, not for the purposes of pointing fingers, but to say, can we make the system better?

SPEAKER_00 53:42

I think this just speaks to the strength and benefit of having these external investigations because they're really there for uh improvement, as you noted, rather than attributing blame or singling out one institution for either failings or successes. It works to say, hey, using this one case, what can we do better everywhere? And I think that's why they did it so successful.

SPEAKER_01 54:00

Another way to think of this, Amir, is, and I'm gonna ask you this question. How do you think this would have gone if this was an MM?

SPEAKER_00 54:05

Really good question. I think, first of all, clinicians generally aren't trained to have uh this degree of reflection about errors. I mean, some of us are naturally inclined to do that. I'd like to believe you'd be good at doing this given your background, but I certainly know myself I wouldn't be very good at doing this. Um secondly, I don't think the goal of a lot of MMs is necessarily to uh find all the factors at play and look at it from such a broad systems perspective. I think these are primarily learning points for individual practitioners. And that's not to say there aren't a lot of learning points in this case, but I think the strength of the HCIP is when they do such a broad thousand-foot back or thousand-meter back view, they actually have a much broader sense of things they can change at the level of the hospital, at the level of the supplier, at things like that, that oftentimes we as physicians are not necessarily focused on in the context of MM rounds. I think you hit it on the head. I think what also stands out about this case is that because it's not blame-centric, because they have that from the outset, because it doesn't feel like anyone's job or individual performance is going to be on the line in this case, they probably had a lot more buy-in from the participants to offer more um rank and forthcoming answers. I don't think they mentioned this, but I certainly know that if some of my colleagues came to me and say, hey, you were in this case, what went wrong? Depending on who that colleague is asking that question, I may have a different answer. And that's not to say that I trust my colleagues more or less than others, but our relationships impact the answers and the dynamics we have. I'm sure we can all attest to this. And so I think having an external investigator who we aren't necessarily uh related to for lack of a better word, provides us a much clearer and unbiased insight.

SPEAKER_01 55:38

I think you hit all the points. Uh, I think first of all, who's asking and for what purpose matters greatly, right? Um, I think if this was an MM, it would have been exactly as you said. I appreciate your vote of confidence in me, but let's say I was some kind of superstar guru, whatever, which I I certainly don't claim to be. Um, but there's only so much one individual can do, and I have no power to really change anything, including local conditions. But in my mind, MMs typically have far more to do with what are we gonna do as a hospital or what are we gonna change as practitioners? And that is not the purpose of this investigation. The purpose of this investigation was to use this reference event so that we could redesign the system, and that requires structure, support, mandate, manpower, all of these things, right? That the HSIB has, and I think it's exactly as you said, part of the benefit of having an external review, and keep in mind that this is a brand new fledgling body, right? They don't have the background that aviation has. People in aviation accidents trust that it's been going on for decades, they know that the purpose is like this. The HSIB, to their credit, has done, I think, a very good job of looking at these reports and over time building up a reputation of doing what they said that they were gonna do, which is actually saying we're not blaming anyone, right? We're not gonna name and shame people, we are going to look at all the factors and we're gonna put people's work in the context that they properly belong, and then we're gonna look at the system, and then we're gonna go from there, right? And so as they fulfill their mandate, we'll hopefully see more of these. But I really do think that this is something that could only be done by an external body that has the mandate that it has, that has the resources that it has, and cannot be done at a local investigatory level. As a matter of fact, the HSIP interim report looks at 31 local investigations. It just tells you that this is not an isolated problem, as you've said, and is really a problem that we need to address on a system level. And we'll take a quick break

Analysis and findings of the wider investigation

SPEAKER_01 57:34

and we're back. Let's now look at the analysis and findings of the wider investigation, so more than just Helen's case, for example. And the first thing that the HSTP looked at was the low frequency of retained foreign objects following invasive procedures. And that indicated that the counting system overall is actually largely successful. However, counting items is not actually as strong systemic as we previously thought, and these events still occur. So the question then is what's the culture look like? And then also how can we quantify this actual risk,

Healthcare professionals' view of the count

SPEAKER_01 58:02

right? So let's look at the culture, and there is a tension between spending more time on something that seems to be largely working well, such as the count, and they need to be efficient with operating room time. Because if other patients don't have access to the operating room, they will be harmed. So let's put this in the context that it actually deserves. And I'd like to pull out some of the quotes that the HSIP obtained from some of the frontline staff. So for example, one of the quotes is there was a perception that retained swab events were, quote, rare, and that this perception influenced staff decisions and actions. One surgeon stated, quote, I'm less worried about the swabs in the sense that how many operations happen every day and we get the swab count right. How many operations happen where we don't get it right. In the grand scheme of things, it's a tiny, tiny, tiny percentage, isn't it? Another quote from the report the need to balance the competing priorities of safety risks with other priorities is noted in a particular report. It states that, quote, the need to prevent the rare occurrence of unintentional retention of items must be balanced against the need to support timely and efficient surgery and other procedures. And that was from the Center for Perioperative Care in 2023. Again, continuing this, quote, the need to balance safety with other priorities such as financial cost, time, loss of productivity, supervision, and maintenance is also reflected in safety science literature and is discussed further in another section. The investigation's interim report highlighted the tendency to focus on human error in those local investigations of retained swab events. However, there is limited understanding of the trade-offs that staff are having to make to balance cost, quality, efficiency, and safety, and the influence of the wider systems such as organizational decisions and trade-offs. So here, these are my comments. Now, here, the HSIP explicitly identifies the conflict that is present in most frontline workers' minds. This is the idea that every minute that is spent attempting to improve a process that works most of the time is a minute of a war time that another patient can't receive. And the HSIP resolves that tension by pointing out, and this is one of my favorite parts of the report, by pointing out that frontline workers generally operate under rules and procedures which provide a normative standard against which their behavior can be judged. In contrast, designers, managers, and such generally operate with more degrees of freedom, meaning these are my comments now, meaning that we may be able to design better sponges and use system measures rather than people focus measures to reduce this risk without a trade-off. So in other words, if you ask the front line, they'll say, well, I can't improve something that's working really well without causing risk downstream to somebody else. And the HSIP says that's the wrong, that's the wrong issue to focus on, right? We can focus on designing something better, and then we won't have those trade-offs. And I think that's the strength of this kind of report. So again, the process of counting has evolved over the years based on what is considered good clinical practice, but there's never been a human factors analysis of the actual count to identify what refinements could be made. So while that may not be the strongest barrier, if we do a human factors analysis of it, maybe we could actually make it stronger, right? For what it's worth. And then the HCIP found that despite various policies identifying that both the surgeon and nurses were responsible, blame can, quote, inappropriately be placed on individual team members when an item goes missing, despite it being a team activity. And and let's be honest, that blame is often apportioned to the nurses. We we know that for the those of us that work there. The HSIP called out facts that the role of the surgeon in the prevention of retained foreign objects is set out in more detail in a particular standard. However, those stand not publicly available, but they are available to purchase, and therefore not everyone has access to them. So that was uh that was an interesting item. The HCIP noted that some surgeons are just not aware of their responsibility for reconciliation and that there isn't any formal training on surgeons of this. So we talked about how I don't know how the count is truly done, and most surgeons probably wouldn't either. The HSIP noted that many other OR practitioners were not aware of the scrub nurses' reconciliation process as we just talked about. Amir, what do you think of this part of the report? You know, I mentioned that part of this is my favorite part because they really looked at how us and the OR might might consider the trade-offs, but if we look take a wider view and so on, that we can see that the system might be able to change. And we're gonna leave the remainder of the findings for the HCB Unintentional Retained Sponges report to another episode. And so this is a good break point because we just looked at all of the findings that they had regarding the reference event, and then we looked at the wider system, and then we looked at healthcare providers' perceptions. The next part of the report, the second half of that report, really talks about risk management principles, and then they apply those risk management principles to the idea of what are the risks involved in unintentional retained sponges. And that's the part that we'll focus on in the next episode. So we'll do what we usually do around this time.

Safety intervention worth mentioning: the hierarchy of intervention effectiveness

SPEAKER_01 1:02:43

Amir, why don't you take us into the safety intervention worth mentioning?

SPEAKER_00 1:02:47

Adam, I appreciate you setting me up to discuss the safety intervention worth mentioning, but I know you feel very strongly about this in the report. So I'm actually gonna send it back to you and I'm gonna riff on this based on what I think. I don't mind that at all. I don't mind that at all.

SPEAKER_01 1:02:59

Actually, you say I feel strongly about this, but you were the one advocating for it just the other moment there, where you were the one who were saying, like, ah, sure surgeons can do a better job, but you know, the high yield stuff is really about how we redesign the system. So you you already you already know this without uh without going through it. We're gonna put this in the show notes, and this is a diagram that I pulled out of one of the reports that really was the hierarchy of intervention effectiveness. And this is the idea that changing the system, and there are different ways that we can change the system. They talk about forcing functions, automation, computerization, simplification, standardization. If we change the system, those are far more effective interventions than the other category, which is called people focused. And this is where education and training come in, rules and policies at the local level, particularly, reminders and checklists and double checks and cross-checking. Those are all people-focused things. And so those are less effective. And I think intuitively we know this, right? Nurse do it better, doctor do it better. Uh here's some training. Oh, you to you attended this MM round, you must now know about this. We've talked about this before, and Amir did a great job of saying, yeah, okay, we can have surgeons who call things out, but that's not where the high yield things are. And that's exactly what this report says, which is if we redesign sponges and we're gonna look at how in the next episode of the Medical Safety Podcast, we look at the specific recommendations. And one of the nice things about this kind of report is they do look at other jurisdictions. They say, what are they doing in the United States? What are they doing in other places that do have different sponges? How effective are they? How much do they cost? Are we bleeding money? Are we losing this and that? Are we gaining this and that? And so it is one of the really big benefits of this kind of investigation body. So when we look at the safety intervention worth mentioning, again, we're talking about this diagram and we're talking about this overall concept about how system-focused interventions are more effective. And again, we get away from what the HCB said earlier, which is this tension at the local level, at the individual or frontline staff level of, well, if I spend more time on this, then it costs me OR time here. Well, we can get around those issues by saying, well, what if we redesigned the sponges, which is a way of redesigning the actual system itself. And so I won't say more than that. I'll simply say have a look at the diagram, look at the uh report, or look at the show notes because we will try and put them in there. I think in some of the distributor, like Apple Podcasts, Spotify, things like that, I don't know that the diagram will actually show up, but if you go on our website, MedicalSafety Podcast.com, we'll definitely have one up there for you as well. And so if I just finish off this point, which is that the HCP says most of the serious incident investigations reviewed were limited in their application to a system-based report, that's because again, they're looking at it at the local level. And you only have so many tools if you're looking at it at a local level. When we look at it from a system-wide level, which again is where a proper investigatory body is perfectly situated to do, when you look at those system based investigation approach, it's based on the idea that we have a better chance of intervening and reducing the risk of those incidents when we actually focus less on the behavior of individuals and more on what tools they're working with, what working conditions they're actually working in. And again, some of the reasons. That people focused solutions are less effective are things like human factors, stress, fatigue, culture, organizational influence, etc. Again, the HSIBS review of local incident investigation aligns with m with much of what Amir and I have been talking about throughout these episodes on this podcast. As a solution is to change the working conditions, and that's what the hierarchy tells us.

SPEAKER_00 1:06:21

The way I interpret the safety intervention worth mentioning today is not that there's one particular tool or effect or thing you can do. It's just to look at this hierarchy of intervention effectiveness as a concept when developing procedures to improve systems function. The things that don't rely on individual practitioners to implement are oftentimes more effective, but are sometimes harder to actually manage from a day-to-day practical perspective. It's very easy for us to tell people just do X, Y, Z. It's very hard for us to develop systems that are foolproof. However, those are oftentimes the things that are best. For example, just thinking about something that is in this vein but not optimally implemented is sometimes us using EMRs to administer blood products. I think all of us who use EMRs have horror stories of needing to give blood to the patients, trying to scan the barcode on the thing to get it to go. But that is one of these quote unquote forcing functions or uh automation computerization functions that make it impossible when functioning ideally to give a patient incorrect or incompatible blood, right? That is something that is built into the system to allow that. Yes, there are implementation issues with that, but I use this as an example to demonstrate like that that is more effective in reducing um inappropriate blood administration than going to two physicians or two practitioners in the or and say, don't forget to double check the blood, don't forget to double check that this matches. If the computer will not let you dispense it, it may be one of those things. I just use this as an example. I don't know if we're going to keep it in, but I wanted to just emphasize that that's what we're talking about here.

SPEAKER_01 1:07:56

Yeah, I think you put a good point there, Amir. The one thing I will say is if you look on the diagram, forcing function is a little bit different than automization and computerization. I think the example of the EMR blood is an example of computerization. And that's the idea that, well, when we scan the barcode, right, then we're not relying on, well, does the blood type really match? Because that's a computerization aspect to it. A forcing function is a little bit more sort of physical design in general. So for example, uh the car won't allow you to shift from park into reverse unless your foot is actively on the brake pedal, right? That's an example of that. Or the microwave oven that uh, you know, shuts off uh if the door is slightly open so that we're not exposed to radiation or or anything like that, right? So those are the forcing functions. It's usually a physical barrier, and that's why that's way up there at the most effective level. But you're right that when we change the system and that computerization, it does make it harder for the people to actually make those errors and so on, as opposed to us just saying, well, be more vigilant and check the blood type and so on.

SPEAKER_00 1:08:57

Okay.

Who can do what tomorrow?

SPEAKER_00 1:08:58

So in terms of who can do what tomorrow, policymaker and government bodies should pass legislation to protect all recordings conducted for safety reviews. This would pave the way for healthcare black boxes to be used, which would provide invaluable evidence for investigators. Adam feels very strongly about this, and I think if this comes first, it opens the door to actually more readily accessible black box recordings. We know that there are recordings that take place in the ORs for education purposes. We know that certain surgeries are recorded for demonstration purposes afterwards. The thing with those is that it's already predetermined. There may be some policies in place about uh blame and litigation related to these at the local level, but have we passed them at the more larger level, more systems level, I can see this opening the door for us to have these more readily available and potentially be used for quality improvement things or audits later on. I use the term audit loosely. What I mean by that is um reflection or investigation of quality improvement uh.

SPEAKER_01 1:09:50

Well, and I always say that uh medical culture doesn't exist in a vacuum, right? Medical culture is informed by legislation, is informed by local policy, is informed by behavior. And a medical policy or any culture isn't static. It changes, and this should be a big shift in favor of that. And as the age in the United Kingdom becomes more prevalent, builds that reputation, I think we will see a shift in the United Kingdom. Uh, and arguably we've already seen that. I mean, they have, as we're gonna see later on, many other safety endeavors that we don't have here in North America, and that just tells you that there is a different uh safety culture or medical culture over there. And so I think not only would it be good and it would pave the way, but it also builds goodwill towards allowing the space to be there for the potential intervention.

Random recommendations

SPEAKER_00 1:10:36

So fun suggestions, random recommendations. Uh Adam, what do you got for us today?

SPEAKER_01 1:10:40

So at the time of this recording, the Roaken Air Force's air demonstration team, which is called the Snowbirds, announced that after this season, which is the 2026 season, it will be their last until 2030 when they have new aircraft. And so they're right now using the iconic CT-114 Tudors, but these were aircraft that the Air Force used as jet transition trainers back in the 1960s, and they've just gotten too expensive to maintain. So they're actually gonna be grounded after this season, and so they are gonna be transitioning to what are called CT-157s or Ciscon 2s, that's what we call them in Canada. They're known worldwide as Pilates PC-21s. These are Swiss triple prop aircraft. Those are the aircraft they're gonna be using in 2030. But if you want to catch the snowbirds, which I just grew up with, uh if you want to catch them before they no longer have the use of the Tudor aircraft, then uh we'll put a link in the show notes as to hopefully this episode will be out before their season is up. You can catch them this summer. Uh, if you're in Ottawa on Canada Day, which is July 1st, uh, you will see them, for example. And they have many other air shows, including the CNE Air Show, which is in Toronto, on the Labor Day weekend, which is uh something like the 7th of September.

SPEAKER_00 1:11:46

So I got this from talking to my parents recently. Uh, the framing is be a tourist in your own city. Um, oftentimes we live in cities that are we get accustomed to them, we have our routines, we don't see cool things, etc., etc. I know a lot of people would say, My city's boring, I've done everything there is to know. But what I would really recommend is actually going out and checking all the tourist hotspots, finding uh new adventures in your own city, actually going into it with eyes wide open and a sense of exploration and discovery in a place that you initially find familiar. I think it's something that gives you more, it gives you a deeper sense of connection to the place you live. I think it opens your eyes to new possibilities and new experience that you otherwise wouldn't have.

SPEAKER_01 1:12:21

Yeah, just double-click on that. I was on TikTok the other day and I saw something. I live in Kingston, and so I saw something for a bookstore that I had been to, and I don't know if it was being billed as sort of a a haunted bookstore or something like that. But the point was that I had seen this and it kind of gave me fresh eyes on it. I'm like, oh yeah, I should go there. I've been there in a little while, and it's kind of like you can be a tourist in your own city.

Outro

SPEAKER_00 1:12:41

That's it for this episode of the Medical Safety Podcast. Tune in next week for part two of this episode where we further review the eight sib uh investigation on retained uh surgical swabs or sponges. I'm Amir Hammond.

SPEAKER_01 1:12:51

And I'm Adam Shahedo.

SPEAKER_00 1:12:55

Adam, take it this time.

SPEAKER_01 1:12:56

As one TV doctor said. What you have to say it. Beautiful day to save class. We are looking for an intern to help do research and make show notes for this show, as well as a producer to help with the technical aspects such as mixing and editing. As this podcast currently receives no outside funding, these would start as volunteer positions, but hopefully if enough people are interested and maybe people donate, it might become a funded position. This would be a great opportunity for medical students, residents, anyone interested in patient safety, critical care, anesthesia, or aviation. If you are a fan of the show, please consider going to wherever you got this podcast and leaving us a positive review. It really helps other people find the show and everyone can learn from your comments. If you're interested in becoming a supporter of the show, please consider going to medical safetypodcast.com where you can make a donation. Even if it's just a dollar or two, it makes a really big difference and we really appreciate it. We'd like to send along a big, big thank you to those of you who have already donated. If you are interested in becoming a patron of the show, please consider going to patreon.com/slash Medical Safety Podcast, where for just five Canadian dollars a month, you can get exclusive access to this and other episodes of the Medical Safety Podcast. Remember, lives are not just saved in the resuscitation bay, countless more lives are saved by the diseases and errors that are prevented and by the work done by scientists, labs, clinicians, and professionals like you working to make every day safer than the last. Thanks very much. Thank you.

Outtakes

SPEAKER_01 1:14:18

And now for ticks. Welcome. Okay. Welcome back to the Medical Safety Podcast. I'm Adam Shahada.

SPEAKER_00 1:14:24

And I'm Amir Hammid.

SPEAKER_01 1:14:26

The Medical Safety Podcast is.

SPEAKER_00 1:14:30

I'll go for it.

SPEAKER_01 1:14:31

Oh, okay. I just do you have the uh okay. You know what? Before we do that, you want to go through our little checklist there? I've got like something to drink, and I've got my all my tablets, and I've got my phone on silent and all that stuff. Where's our other checklist here?