Blogs

This article was reviewed for technical accuracy and clarity by Dr Nigel Roberts, Associate Divisional Director, with a keen interest in patient safety, the WHO checklist and NatSSIPs.

NatSSIPs 2, Requirement 6 within the NatSSIPs Eight

For those working routinely with NatSSIPs, the distinction matters, and it’s worth being explicit.

National Safety Standards for Invasive Procedures 2 is the current national standard. It deliberately separates organisational standards from sequential standards, recognising that governance alone does not deliver safety at the point of care.

The NatSSIPs Eight sit firmly in the second category. They are the sequential, patient-facing standards that must be executed, in order, for every invasive procedure.

Requirement 6 sits within those sequential standards, i.e. reconciliation of items

That positioning is not incidental, it is a clear signal about where risk actually manifests.

Requirement 6 is a sequential control, not a policy statement

Requirement 6 is often described loosely as “the counting standard,” but that shorthand misses the point.

Requirement 6 is about making sure items  are accounted for, before, during and after the procedure itself, not relying on paperwork, policies, or checks done after the event.

It assumes that:

• Counting will occur
• Teams are trained
• Policies exist

What it tests is whether the process remains reliable under real conditions, including escalation, interruption, fatigue and handover. That is why it sits in the sequential standards rather than the organisational section of NatSSIPs 2.

Why this distinction still matters

Despite near-universal adoption of NatSSIPs, retained swabs continue to be reported as Never Events by NHS England.

For experienced safety leads, this is not surprising.

Manual counting processes, even when well designed, are inherently vulnerable to the same pressures NatSSIPs was designed to mitigate. Investigations by the Healthcare Safety Investigation Branch have repeatedly highlighted that failures are rarely due to ignorance of process. They arise when systems depend on uninterrupted human performance in environments where interruption is unavoidable.

In that context, Requirement 6 is less about reinforcing counting discipline and more about asking whether the system as a whole can tolerate disruption.

What the NatSSIPs Eight implicitly demand

The NatSSIPs Eight do not prescribe solutions. They define outcomes.

Requirement 6 requires that, before the end of an invasive procedure, there is confidence, not assumption, that all swabs, sharps and instruments are accounted for.

For many organisations, that is driving a gradual shift:

• Away from reliance on verbal confirmation alone
• Toward independent, in-procedure assurance
• Toward controls that function during the case, not after it

This is consistent with broader patient safety thinking, where resilience is designed into the system rather than expected of individuals.

Maternity as the proving ground

Maternity theatres continue to act as a stress test for Requirement 6.

Urgency, rapid escalation, multiple team changes and emotional intensity expose the limits of manual-only controls more quickly than almost any other setting. That does not make maternity exceptional, it makes it illustrative.

If a Requirement 6 approach is robust enough for maternity, it is likely robust enough elsewhere.

iCount within the sequential standards

iCount is positioned deliberately within the sequential execution space, not as an organisational governance intervention.

It does not replace counting, nor does it attempt to redesign clinical workflow. Its role is to add a system-level, physical assurance layer that supports Requirement 6 by reducing reliance on memory and verbal confirmation at the point where failure has the greatest consequence. In NatSSIPs terms, it is aligned with the intent of the NatSSIPs Eight, supporting consistent execution of the sequential step concerned with retained foreign objects.

Closing thought

NatSSIPs 2 is clear that safety is delivered through execution, not documentation.

Requirement 6, as part of the NatSSIPs Eight, is where policy meets reality. Organisations that treat it as a procedural formality will continue to see residual risk. Those that treat it as a system design challenge are more likely to achieve the reliability NatSSIPs is actually aiming for.

That distinction is increasingly central to how retained swab risk is being addressed, and it is the context in which iCount is deliberately positioned.

References: NatSSIPs 2 guidelines