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Retained surgical swabs remain one of healthcare’s most preventable Never Events.
Even with decades of safety protocols and manual counting, incidents still occur, sometimes after childbirth, sometimes after major surgery, with devastating results for patients and staff.

The recent iCount Live Launch explored why retained surgical swabs still happen and how innovation can make operating rooms safer and more reliable.

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Why Retained Surgical Swabs Still Happen

Experts across clinical, safety, and patient-advocacy backgrounds agree that despite training and checklists, retained swabs occur because workflows are complex and depend too heavily on human attention.

Dr Aditi Desai, NHS consultant and inventor of iCount, explained:

“Counting swabs manually works in theory, but in busy theatres it relies on tired people under pressure. We needed a better system that supports teams, not adds to their load.”

Catherine O’Reilly, Patient Safety Officer at UHBW, added:

“We often add more steps, thinking it improves safety, but complexity itself becomes the risk.”

The Human Impact of a Retained Swab

Behind every retained surgical swab is a patient’s story.
Laura Fleming, patient advocate and retained-swab survivor, shared the personal and emotional cost of such incidents — for both patients and clinicians.

“It’s not just about what happens in theatre — it’s the fear and loss of trust afterward. These events stay with everyone involved.”

Her story highlights why preventing retained surgical items is not only a technical issue but a human one.

The Human Impact of Retained Swabs

Behind every Never Event is a person.
Laura Fleming, patient advocate and retained swab survivor, shared her experience of the physical and emotional impact.

“It’s not just about the moment it happens — it’s the loss of trust, the fear, and the feeling that something avoidable wasn’t prevented.”

Her story is a powerful reminder that improving surgical safety isn’t only about technology — it’s about protecting people: patients and staff alike.

Preventing Retained Surgical Swabs Through Innovation

The iCount Safety System, developed by Dr Aditi Desai, is a practical example of surgical-safety innovation.
It’s designed to make swab counting faster, safer, and more reliable by reducing manual steps and providing real-time visual confirmation.

Rather than layering more procedures, iCount simplifies the process, giving scrub nurses and surgeons confidence that every swab is accounted for.

As Catherine O’Reilly put it:

“We can’t keep adding checklists to fix the same issue. iCount replaces uncertainty with confidence.”

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A Collaborative Approach to Surgical Safety

The iCount launch isn’t a commercial rollout, it’s the start of a collaborative phase.
The team is partnering with hospitals and surgical units to pilot iCount, collect data, and refine the system before full adoption.

“We want to co-design with frontline teams,” said Dr Desai. “That’s how we’ll finally prevent retained surgical swabs, by building solutions that fit real clinical workflows.”

Get Involved: Become a Pilot Partner

If your hospital, theatre, or patient safety team would like to collaborate on a pilot project, we’d love to hear from you.

📧 Contact: info@icountcorrect.com
🔗 Follow us on LinkedIn: linkedin.com/company/icountcorrect

Together, we can move from Never Events to Never Again.

Disclaimer: This content is for awareness and improvement. It does not name hospitals or assign blame and is not medical or legal advice.