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The national organisation Healthcare safety Investigation Branch (HSIB)
suggests - design of the swabs being used presently as a major issue.
Undue emphasis has been given to 'human error'.
Humans can make mistakes but after fall into 'error traps' made by poor design and unfavourable conditions .We present a solution that is 'Safer by design'


"Counting before and after" is a fallible system. If you have 52 cards in a deck, you will get them wrong at a predictable rate
and not realise it when you count them at different times." Atul Gawande - WHO Checklist Pioneer
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