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In the fast-paced, high-pressure environment of an operating theatre or maternity ward, patient safety is always the top priority. Yet, despite the dedication and vigilance of clinical teams, retained surgical swabs, classified as “Never Events”, continue to threaten patient wellbeing and staff peace of mind. Globally, these incidents cost healthcare systems an estimated £2.1 billion each year, not to mention the emotional and professional toll on teams involved (NHS England, 2023; National Reporting and Learning System, 2022).

The Human Cost of Manual Counting

Traditionally, swab counting relies on manual processes, checklists, and double-checks between team members. But even with the most rigorous protocols, human error remains a persistent risk, especially in emergencies or complex procedures. Studies show that retained swabs account for 8–10% of all Never Events (BMJ, 2024), and every incident can result in significant legal costs, harm to patients, and even staff leaving medicine due to the emotional aftermath.

As one consultant put it, “I would be devastated. Beyond devastated.” The psychological impact on clinicians is real, often leading to increased stress and burnout.

Why Human-Centric Design Matters

The solution isn’t about replacing people, it’s about supporting them. A human-centric approach to swab counting means designing systems that fit seamlessly into clinicians’ workflows, reduce cognitive load, and provide real-time feedback. This empowers staff to focus on patient care, confident that technology is there to back them up.

In short Human-centric swab counting supports clinical teams by reducing cognitive burden and standardising best practices.

iCount, for example,  was developed in close collaboration with clinical teams, with every feature designed to address the real-world challenges faced by theatre and maternity staff. The current focus is on embedding iCount seamlessly into existing workflows, making it easy to adopt without disrupting established practices. Looking ahead, advanced options like AI-powered automation and electronic medical record (EMR) integration are in development, ensuring that the system will evolve to provide even greater support in the future.

The Evidence for Change

Recent research published in the BMJ highlights that “iCount has the potential to reduce or prevent retained swabs after vaginal deliveries along with appropriate policies, training, and teamwork.” Users report greater time efficiency and a stronger sense of safety compared to traditional two-person manual counts (BMJ, 2024).

Moreover, the financial argument is compelling: a single retained swab incident can cost a hospital up to £300,000 in litigation and lost reputation (NHS Resolution, 2023). Investing in automated, human-centric solutions like iCount offers a fraction of that cost and could eliminate the risk entirely.

Embracing a Culture of Safety

A human-centric approach is about more than just technology. It’s about creating a culture where safety is embedded in every procedure—supported by ongoing training, open communication, and a willingness to adopt innovations that protect both patients and staff.

Evidence from simulation studies and usability testing have shown positive feedback from clinical teams, highlighting potential for fewer incidents, improved efficiency, and greater team confidence compared to traditional manual counting. As iCount moves towards real-world adoption, it’s designed to bring these benefits into everyday practice, helping teams shift from fear of error to assurance of safety.

Conclusion

Creating safer workflows starts with putting people at the centre, supporting clinicians with technology that augments their expertise and vigilance. As the NHS and healthcare systems worldwide strive to eliminate Never Events, solutions like iCount represent a crucial step forward in patient safety design.

References:

• NHS England. (2023). Never Events data.
• BMJ. (2024). “iCount: Reducing Retained Swabs in Clinical Practice.”
• National Reporting and Learning System. (2022). Patient Safety Incident Reports.
• NHS Resolution. (2023). Costs of Litigation in the NHS.

Ready to learn more about how iCount is helping hospitals create safer workflows? Get in touch to discuss a risk-free pilot program for your team.