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Related Experiment Videos

Automatic detection and notification of "wrong patient-wrong location'' errors in the operating room.

Warren S Sandberg1, Matti Häkkinen, Marie Egan

  • 1Harvard Medical School and Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA. wsandberg@partners.org

Surgical Innovation
|October 15, 2005
PubMed
Summary

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Automated patient tracking systems can prevent wrong-patient errors. This study shows real-time monitoring accurately detects and alerts staff to patients in the incorrect operating room (OR), improving patient safety.

Area of Science:

  • Biomedical Engineering
  • Health Informatics
  • Patient Safety Technology

Background:

  • Human error in patient identification and location can lead to critical
  • wrong-patient-wrong-procedure
  • events.
  • Existing manual processes for assuring patient location are fallible.
  • Automated systems are needed to enhance patient safety and workflow accuracy.

Purpose of the Study:

  • To develop and evaluate an automated system for real-time patient location monitoring.
  • To detect and annunciate
  • wrong-operating room (OR)
  • events automatically.
  • To assess the system's accuracy and speed in identifying and reporting errors.

Main Methods:

Related Experiment Videos

  • Implementation of an active infrared/radio frequency identification (RFID) tracking system.
  • Real-time comparison of patient location data against an "expected process" model.
  • Automated flagging of deviations and generation of alerts via a hospital paging system.

Main Results:

  • The system successfully detected all instances of patients in the wrong operating room (OR).
  • Incorrect OR locations were identified with high accuracy within 0.50+/-0.28 minutes.
  • All
  • wrong-OR
  • events were correctly annunciated through the paging system.

Conclusions:

  • Current technology enables robust, automated monitoring of patient flow within hospitals.
  • Automated systems can provide real-time decision support and effectively notify stakeholders of errors.
  • This technology significantly enhances patient safety by preventing
  • wrong-patient
  • and
  • wrong-OR
  • events.