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NHS England’s policy sets an important benchmark for patient safety. Unintentionally retained swabs that meet the published criteria are classified as Never Events. Staff should recognise this risk and understand their responsibilities for counting, reporting and learning.

Policy is an essential part of a safe system. Systems engineering helps translate that policy into reliable everyday practice by designing equipment and processes that support staff, particularly during interruptions, handovers and complex procedures.

Swab counting is a physical task. A physical checklist can therefore be a valuable adjunct, making each item’s status visible and providing a clear cue when something still needs to be accounted for.

This is what iCount aims to provide. Its docking system acts as a physical checklist, with a designated position for each swab. Visual and tactile cues are designed to support counting and help teams recognise discrepancies.

Used alongside established counting procedures, training and teamwork, iCount aims to make swab accountability easier to see and verify; bringing the expectations of patient safety policy into the physical clinical workflow.