iCount: a human-factors engineered solution to vaginal swab retention – an early-stage innovation report

Abstract

### WHAT ARE THE NEW FINDINGS #### HOW MIGHT IT IMPACT ON HEALTHCARE IN THE FUTURE Although uncommon, unintentionally retained surgical items remain a persistent and poorly understood medical error with the potential to cause significant harm. They are termed patient safety ‘never events’ and are considered unacceptable and largely preventable.1 The most commonly retained surgical item is the surgical swab, also known as ‘sponge’ in the USA, with the highest rates of swab retention found in the maternity setting. The UK never events database identifies vaginal swabs (used during perineal trauma repair) as the source of the largest number of swab retention events.2 3 NHS England data identifies 338 separate incidents of vaginal swab retention between 2012 and 2022 with evidence of global under-reporting due to the significant reputational impacts of these incidents as well as the difficulty in diagnosis and identification of error.1 3–6 This long-standing problem, also called ‘Gossypiboma’, was first reported in 1884 by the American Obstetrician and Gynaecologist Dr Wilson. …