Swabs are counted in and counted out, by two people, out loud, and the count has to match before a patient is closed. Ours matches everywhere but theatre 3, where the closing count is one higher than the opening one, which is the direction nobody has a procedure for.
I have scrubbed for eighteen years and I am a theatre practitioner in a general list.
How the count works, because it is more rigorous than people imagine.
Swabs come in sealed packs of five. The scrub practitioner and the circulating practitioner open them together, separate them, and count them out loud, and the number goes on the whiteboard. Every additional pack opened during the case is added to the board the same way.
At the end you count what is on the trolley, what is in the rack, and what is in the kick bucket, and the total has to equal the total opened. Two people, out loud, both of them signing.
If it does not match, nothing else happens. You search, you re-count, you check the drapes and the floor and the bin, and if it still does not match the patient is X-rayed on the table, because swabs are woven with a radio opaque marker precisely so they can be found.
I have been part of four counts that did not match. All four were found: one under a drape, one in a bin liner, two miscounted at the start.
In theatre 3 the closing count comes out one higher.
Not one missing. One extra.
Twelve times in about three years, that I have been part of or been told about by people I believe.
There is no procedure for one extra, and that is not an oversight in the procedure.
A swab that appears cannot have been left inside anybody. The risk the count exists to catch is the other direction. So a count that is one over is, in patient safety terms, nothing at all.
What it is, is a swab in the bucket that nobody opened.
What has been checked.
The packs. They come in fives, sealed, and the seal is opened in front of two people. We have counted the packs into the theatre at the start of a list and out at the end, unopened ones included, for a whole list, four times.
The pack count is right. The numbers on the board are right. There is one more swab in the bucket than the board says.
The manufacturer. A pack of six instead of five would explain the whole thing and it is exactly the sort of thing that happens, so we kept the wrappers of every pack for two months and counted every one at the point of opening.
No pack has ever had six in it. I would have been delighted.
The other theatres. Five of them, same suite, same stock, same staff rotating through. It does not happen in any of them.
The swabs themselves.
They look like our swabs. Same size, same weave, same marker, and the marker is there because I have looked at it under the light.
In 2023 a colleague kept one. That is not something either of us should have done and I am putting it down anyway. It went into a specimen pot in her bag and to a friend of hers who works in a different trust's sterile services.
His answer, by text, is that it is a standard four ply gauze swab of a type still made, and that the marker thread is a pattern that was discontinued by that manufacturer some years ago, and he asked her where she had got an old one.
What happens on the day.
The count is done, it comes out one over, and the discrepancy is recorded on the count sheet as a discrepancy resolved, with a note. The consultant is told. The patient is fine and has always been fine and is not X-rayed, because there is nothing to look for.
It has been reported twice as an incident on the electronic system. Both were closed as no harm, with a recommendation to review counting practice in theatre 3.
Our counting practice in theatre 3 is the same as it is in theatre 1 and I have been reviewed doing it and I was found to be doing it correctly.
What I do.
I count. Twice, out loud, the way I was taught, and I say the number and my colleague says the number.
The thing I changed is the bucket.
The kick bucket sits at the foot of the table and you drop into it without looking, which is the point of it. At the end you tip it out onto a counting rack and go through it.
I put the bucket where I can see it now, and I look at what is in it during the case, which slows me down by nothing and which two people have commented on.
The reason is a list in October 2023, a straightforward gallbladder, four swabs opened and none of them yet used, and I glanced into the bucket at about twenty past nine because I had dropped a suture wrapper into it.
There was a swab in the bottom of it, folded the way we fold them, soaked through, and the case had not bled at all.