A Retained Swab, a Sixteen-Hour Shift and a Request for Silence
Three days after an open cholecystectomy, a 61-year-old woman develops fever and abdominal pain. CT shows a retained surgical swab. The operation had been converted to an emergency because of bleeding, and the swab count was interrupted mid-procedure. The scrub nurse had worked a 12-hour day shift and then stayed on call, and had been awake for 20 hours when the count was abandoned. The surgeon tells the team to "manage it quietly and take it out on Monday". The patient asks the nurse why she is still febrile.
1. What must the patient be told, by whom, and how?
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She must be told the truth, promptly and in understandable language: a swab was left during the operation, this is why she has fever and pain, what will be done and when, and what the likely course is. The surgeon, as the operator and responsible clinician, should lead the conversation, with the nurse present for continuity and support.
An apology for what happened is appropriate and is not an admission of legal liability; concealment, by contrast, is both an ethical failure and a risk factor for the institution. She should be offered a copy of her records and told how to raise a complaint before the patient rights commission.
"Quietly, on Monday" is not acceptable. Delay exposes her to sepsis and destroys trust. If the surgeon refuses, the nurse should escalate to the head of department, the medical director and the patient rights commissioner, and document the escalation.
2. What reporting and investigation must follow, and what is the nurse's own position?
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Reporting. An internal adverse-event report must be filed immediately; a retained swab is a serious adverse event and triggers notification in line with the institution's quality system and national reporting requirements. The report should describe facts and system factors, not allocate blame.
Investigation. A root-cause analysis should examine: the counting protocol and who may authorise its interruption; how the bleeding emergency was managed; staffing at 20 hours of wakefulness; the availability of radio-detectable swabs; and the handover. The findings should produce changes, not just a memo.
The nurse. She must give an honest account and is entitled to representation and to see the institution's procedure. Fatigue is a mitigating system factor, but abandoning a count without a documented, authorised alternative is a professional failing. The employer's decision to roster her for 12 hours plus on-call is a separate breach of working-time and safety duties and belongs in the same analysis.
3. How should the fatigue and working-time issue be framed in the investigation and afterwards?
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Frame it as a foreseeable, manageable risk that the employer owns, not as a personal weakness of the nurse.
The employer must organise work so that rest periods and maximum working time, including on-call, are respected, assess the risk of fatigue in the workplace risk assessment, and provide cover so that a single nurse is not the only safeguard against a count error. The investigation should establish the actual hours worked, the rest taken, the staffing at the time of the emergency and whether the count was interrupted in line with policy.
Afterwards: revise the rota, define who may authorise an interrupted count and what must happen before closure, ensure radio-detectable swabs, and give the team feedback. Disciplinary measures may still be appropriate, but a system that treats an exhausted nurse as the sole cause will produce the same event again.