The Human Impact of Retained Surgical Swabs
Behind every retained swab is a story of unnecessary harm, preventable suffering, and systemic failure. iCount is here to change that.
Real Stories, Real Impact
45-year-old female patient underwent open cholecystectomy for gallstone disease. Seven days following the operation, the patient complained of pain abdomen, vomiting and fever associated. She was re- operated because of suspicion of a tumour. A retained swab was found. This patient sadly died due to severe sepsis that had taken hold by then. It was tragic for the patient and the family.
The Surgeon went through tremendous mental agony, humiliation and also charges of negligence.
https://doi.org/10.1007/s12262-012-0446-3
A nurse in a high-pressure OR was blamed for a retained swab incident, leading to severe patient harm. Systemic issues were overlooked, and the nurse left the profession. iCount supports systemic improvements to prevent such outcomes.
An 83-year-old man underwent bowel surgery but suffered complications for 20 months before a retained swab was identified, leading to respiratory failure and death. iCount could have prevented this tragedy.
3 year old girl had an operation for a pelvic tumour. She underwent surgical resection of the mass. The child subsequently came back after 4 months with symptoms and had to undergo another procedure to remove an accidentally retained swab.
Biomedical Journal of Scientific & Technical Research
May, 2019, Volume 17, 4, pp 13010-13012
Helen, a 59‑year‑old patient who underwent a 5‑hour coronary artery bypass graft (CABG) surgery, received a post‑operative chest X‑ray that revealed a retained surgical swab in her chest. She was returned to theatre for a second operation to remove this swab, but a follow‑up X‑ray then identified a second retained swab in the same area. This necessitated a third surgical intervention to extract the remaining swab . The HSSIB investigation flagged this as a “Never Event” and highlighted systemic issues in the swab‑count reconciliation process, such as human factors, environmental pressures in theatre, and limitations in swab design . The report led to important safety recommendations for human‑factors redesign of counting processes, frameworks, and technology integration to prevent similar incidents
https://www.hssib.org.uk/patient-safety-investigations/retained-surgical-swabs/investigation-report/
A nurse in a high-pressure OR was blamed for a retained swab incident, leading to severe patient harm. Systemic issues were overlooked, and the nurse left the profession. iCount supports systemic improvements to prevent such outcomes.
Its bad enough to have kidney cancer and removal of one kidney, but to be brought back to the hospital within a week with problems and then have a re-operation for a retained swab is another challenge. A 59 year old gentleman had to go through this. He eventually recovered but it was a long course.
https://doi.org/10.1016/j.jflm.2023.102574
What Medical Professionals Say
Hear from surgeons and OR staff who have implemented iCount in their facilities.
Dr. B. Johnson
Designaton
Since implementing iCount, we’ve seen a significant reduction in surgical errors.
Dr. B. Johnson
Designaton
Since implementing iCount, we’ve seen a significant reduction in surgical errors.
The iCount Difference*
7 hours
Potentially frees up to 7 hours a day in maternity care alone
97%
Staff compliance with swab counting protocols improved from 70% to 97% after introducing iCount.
100%
Implementation of the iCount system resulted in a 100% reduction in near-miss incidents.
98%
user confidence in iCount
* BMJ - iCount: a human-factors engineered solution to vaginal swab retention – an early-stage innovation report Know more