NCT05373342

Brief Summary

Accidentally retained surgical items or swabs are well-recognised errors that result in adverse consequences for patients. This error is one of the commonest "Never Events" - patient safety incidents that are considered preventable. Although uncommon, these incidents can have devastating consequences. Retained surgical items have 70% re-interventions, reaching 80% morbidity and 35% mortality. Swabs or sponges are like small towels that soak up blood and body fluids so that the surgeon can visualise the operating area effectively. Swabs are used in all areas of surgery which include operations on the tummy, chest, limbs. They are also used in the vagina during childbirth, to assess for tears and to minimise blood oozing from the vagina. The common risk factors for this error are out of hours surgical or childbirth procedures, multiple handovers in the care of the patient, raised BMI (Body Mass Index) and unplanned change to the operative intervention. As the name suggests, a 'never event' should never happen in the first place. Never. Unfortunately, this is not the case. Incidents involving surgical swabs being left behind, particularly during a caesarean section or a perineal repair following a vaginal birth, are still happening despite over 100 years of institutional awareness of the problem and tentative solutions being implemented in clinical practice. never-event incidents involving retained surgical swabs are a widespread problem affecting healthcare systems worldwide. It is therefore reasonable to ask the question: why are surgical swabs being left behind and what can be done to prevent this from happening?

Trial Health

65
Monitor

Trial Health Score

Automated assessment based on enrollment pace, timeline, and geographic reach

Enrollment
70

participants targeted

Target at P25-P50 for all trials

Timeline
12mo left

Started Sep 2026

Shorter than P25 for all trials

Status
not yet recruiting

Health score is calculated from publicly available data and should be used for screening purposes only.

Trial Relationships

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Study Timeline

Key milestones and dates

First Submitted

Initial submission to the registry

May 3, 2022

Completed
10 days until next milestone

First Posted

Study publicly available on registry

May 13, 2022

Completed
4.3 years until next milestone

Study Start

First participant enrolled

September 1, 2026

Expected
1 year until next milestone

Primary Completion

Last participant's last visit for primary outcome

September 1, 2027

Same day until next milestone

Study Completion

Last participant's last visit for all outcomes

September 1, 2027

Last Updated

April 9, 2026

Status Verified

April 1, 2026

Enrollment Period

1 year

First QC Date

May 3, 2022

Last Update Submit

April 8, 2026

Conditions

Outcome Measures

Primary Outcomes (5)

  • Rate of device count accuracy (conspicuity of spotting a missing swab) measured via staff questionnaire feedback

    12 months

  • User experience about general look and feel and user satisfaction (overall perception) measured via staff questionnaire feedback

    12 months

  • User perception about the confidence about the accuracy of the count with use of the device and thoughts about intention to use, if available (functionality) measured via staff questionnaire feedback

    12 months

  • User perception about the ease of learning of how to use the device measured via staff questionnaire feedback

    12 months

  • User perception of how device works within current system measured via staff questionnaire feedback

    12 months

Study Arms (2)

iCount Device

A novel external device which can count the swabs and surgical tampons used during childbirth in an objective and validated manner.

Device: iCount system assembled with swabs

User Feedback Survey

Feedback will be taken from 20 users including midwives/ doctors. Users will be emailed an online survey or given the same survey as a printout to complete. All 20 users will also then also be approached to have a semi-structured interview. 10 of the users who first express interest will be interviewed.

Interventions

Designed as single use. Intended purpose - To be used to count swabs and tampons after childbirth in an objective manner. This is intended to be used in women during and after childbirth.

iCount Device

Eligibility Criteria

Age18 Years+
Sexfemale
Healthy VolunteersYes
Age GroupsAdult (18-64), Older Adult (65+)
Sampling MethodNon-Probability Sample
Study Population

Pregnant women during labour

You may qualify if:

  • Midwifery lead and consultant lead patient older than 18 years.
  • Consented to participation after an informed choice.

You may not qualify if:

  • Under 18 years of age
  • Antenatal (before labour):
  • Patients who have a high risk of expected/unexpected maternal, fetal or neonatal deterioration such that during birth, the focus of attention would be towards safe patient care and observation required for using the swab-counter device system would not be possible such as :
  • Patients who are seriously unwell and require high dependency care.
  • Maternal cardiac conditions
  • Severe pre-eclampsia
  • Fetal anomalies where neonatal deterioration is expected (These will be relatively rare conditions where the doctor/midwife would decide to not recruit the patient)
  • Intrapartum and postpartum factors:
  • Patient having an emergency Caesarean section instead of a vaginal birth due to maternal or fetal indication.
  • Eclampsia (seizure/fitting in labour or after delivery)
  • Maternal cardiac conditions requiring high dependency care
  • Severe sepsis requiring high dependency care
  • Fetal anomalies where neonatal deterioration is expected

Contact the study team to confirm eligibility.

Sponsors & Collaborators

MeSH Terms

Conditions

Foreign Bodies

Condition Hierarchy (Ancestors)

Wounds and Injuries

Study Officials

  • Aditi Desai

    The Royal Wolverhampton NHS Trust

    PRINCIPAL INVESTIGATOR

Central Study Contacts

Study Design

Study Type
observational
Observational Model
COHORT
Time Perspective
PROSPECTIVE
Sponsor Type
OTHER GOV
Responsible Party
SPONSOR

Study Record Dates

First Submitted

May 3, 2022

First Posted

May 13, 2022

Study Start (Estimated)

September 1, 2026

Primary Completion (Estimated)

September 1, 2027

Study Completion (Estimated)

September 1, 2027

Last Updated

April 9, 2026

Record last verified: 2026-04