A Story with a message *
Maternity care is calling out for strategic policy action to improve quality and safety.
Although there are many initiatives to improve care, there is work to be done, as highlighted by reports such as the Ockenden review. Retained swabs are one of the causes of avoidable harm.
Never events are indicators of the need to design better systems at all levels inviting interdisciplinary, multi-professional engagement with a user and patient-centric approach.
Our aim in healthcare is to try and prevent all avoidable harm.
Good design along with well trained and motivated staff working in a just culture environment, deliver safer care.
iCount device system is one such system that has been developed to 'design out' this medical error in a failsafe manner.
As a team, we have other concepts that are in development that are also based on this holistic approach.

A Simple Intuitive Cost-Effective Solution to Prevent Surgical Items Accidentally Left Behind

Patent published UK IPO and WIPO

Safer by Design

 iCount makes it easy to do the right thing.
York Health Economic Consortium, an independent, highly reputed organisation has done a detailed cost-benefit analysis. Although these events are not common, the litigation, legal costs associated, morbidity and staff cost amount to several million per year. We intend to make it available at a sustainable and cost-effective price which is much lower than the economically justifiable, cost-neutral price as demonstrated by this analysis.
This will bring significant cost savings to the NHS.
Mother and Baby on Floor
Winners of 'Collaboration of the Year' and
highly commended in the 'health and wellbeing' category at the Staffordshire and Keele University
'Breaking the Mould' awards celebrating Promising innovations
#KeeleBTMAwards  Dec 2020
Winners of the 'RCOG Sir William Gilliatt award' in the poster category at the RCOG World Congress 2021
Link to e-poster

We believe in Co-design and Co-production

A Usability study was done in High Fidelity Simulation Clinical environment (2020) by MedtechNIHR, University hospital Birmingham showed positive feedback leading to design changes and prototype iteration. Business Bridge, Keele University provided the initial 'Seed funding' for prototype development.

When Patients, Carers, Nurses, Midwives, Doctors, healthcare service managers, Engineers, Research academics, Business developers, Universities, Funding bodies, Technology development organisations come together....Amazing things happen

Patient Public Involvement (PPI) done by NIHR Surgical MIC, Leeds (2020)
Some of the comments from the healthcare service users were :
"It is shocking that surgical swabs are still left behind in this day and age. The first case series was reported in 1884. We thought that we should have overcome this problem by now"

"It would be good to have a failsafe engineering solution rather than just rely on counting which is susceptible to human error."

Patients and healthcare service users provided some excellent suggestions for user-centric design, integration into the current workflow and about raising awareness about patient safety
We used these for developing a systems engineering approach
*Although the story is based on real stories, names and situations have been changed.Any resemblance to real persons is purely coincidental
    The Challenge


 Over 100 retained surgical items every year in England 
The USA -over 3000 every year. Canada -around 160 every year.
Thousands of these incidents over the world happen every week.
The commonest item left behind is a ‘surgical swab or sponge’.
(published NHS England/Improvement data)
Effects are pain, infection, re-operation, psychological trauma, inability to bond with the baby, long term discomfort and rarely, death. Retained swabs are called surgical "Never Events" which should never really happen.
iCount is a registered trademark (UK Intellectual property Office) with patent published (UK IPO) and with complete freedom to operate
Our Collaborators and Supporters
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National reports references:
1. Healthcare Safety Investigation Branch(HSIB) is the first in the world to carry out independent healthcare investigations to improve healthcare at the system level.Their recent report highlights a common ‘Never Event’ that leaves women at risk of harm after childbirth.Click here - HSIB report puts a spotlight on the recurrent problem of retained swabs after childbirth.
2. Surgical Never Events. NHS Improvement (2018). Learning from 38 cases occurring in English hospitals between 2016 and 2017.
3. UK NHS National Patient Safety Agency. Rapid response report NPSA/2020/RRR012.Reducing the risk of retained swabs after childbirth and perineal suturing.
4. WHO Safe surgery Guidelines - Safe Surgery saves lives (2009) recommend checking and documenting whether the count is correct but recognises the dual error of leaving an item inside the patient and a counter-balancing discount resulting in a 'false correct' count.
WHO encourages using alternative methods for tracking and counting surgical swabs.
5. The Organisation for Economic Co-operation and Development (OECD) Surgical Safety indicators - retained surgical swabs.
Measuring Patient Safety: Opening the Black Box (2018).
6. Reducing the risk of retained swabs after vaginal birth. British Medical Journal 2010;341:c3679
7. US Joint Commission report: Preventing unintended retained foreign objects


8. The Australian Commission on Safety and Quality in Health Care (the Commission)- Sentinel events list- retained swabs
9. The New Zealand Health Quality and Safety Commission, New Zealand. Retained vaginal swabs following childbirths- problem and prevention strategies.Sentinel events. Dec 2015.
10.Spotlight on patient safety. Minnesota Department of Health. Focus on retained foreign objects- vaginal sponges which contribute significantly to…. www.health.state.mn.us/patientsafety and similar reports from each US state.
11. Care Quality Commission.Inspection  Single Assessment Framework MATERNITY. Swab Count audits. pg11
11. Reducing the risk of retained swab after perineal suturing, Malaysia Guidelines 2019.