This Article Full Text (PDF) References Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Sandberg, W. S. Articles by Rattner, D. Search for Related Content PubMed PubMed Citation Articles by Sandberg, W. S. Articles by Rattner, D. Social Bookmarking                         What's this?

Automatic Detection and Notification of "Wrong Patient—Wrong Location" Errors in the Operating Room

Harvard Medical School;Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Clinics 3, Boston, MA 02114 (wsandberg{at}partners.org).

Matti Häkkinen, MS

General Electric Medical Systems Information Technology

Marie Egan, RN, MS

Department of Nursing

Paige K. Curran, MS

Research Assistant, Massachusetts General Hospital

Pamela Fairbrother, BA

Research Assistant, Massachusetts General Hospital

Ken Choquette, BS

Radianse, Inc, Lawrence, MA

Bethany Daily, MHA

OR Information Systems, Massachusetts General Hospital

Jukka-Pekka Sarkka

General Electric Medical Systems Information Technology

David Rattner, MD

Harvard Medical School and Department of Surgery, Massachusetts General Hospital, Boston, MA

When procedures and processes to assure patient location based on human performance do not work as expected, patients are brought incrementally closer to a possible "wrong patient—wrong procedure" error. We developed a system for automated patient location monitoring and management. Realtime data from an active infrared/radio frequency identification tracking system provides patient location data that are robust and can be compared with an "expected process" model to automatically flag wrong-location events as soon as they occur. The system also generates messages that are automatically sent to process managers via the hospital paging system, thus creating an active alerting function to annunciate errors. We deployed the system to detect and annunciate "patientin-wrong-OR" events. The system detected all " wrongoperating room (OR)" events, and all "wrong-OR" locations were correctly assigned within 0.50 ± 0.28 minutes (mean ± SD). This corresponded to the measured latency of the tracking system. All wrong-OR events were correctly annunciated via the paging function. This experiment demonstrates that current technology can automatically collect sufficient data to remotely monitor patient flow through a hospital, provide decision support based on predefined rules, and automatically notify stakeholders of errors.

Key Words: radio frequency identification tracking • wrong-operating room events • automated patient location system • hospital process monitoring

Surgical Innovation, Vol. 12, No. 3, 253-260 (2005)
DOI: 10.1177/155335060501200312


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				R. H. Epstein, F. Dexter, and E. Piotrowski Automated Correction of Room Location Errors in Anesthesia Information Management Systems Anesth. Analg., September 1, 2008; 107(3): 965 - 971. [Abstract] [Full Text] [PDF]

				M. T. Egan and W. S. Sandberg Auto Identification Technology and Its Impact on Patient Safety in the Operating Room of the Future Surgical Innovation, March 1, 2007; 14(1): 41 - 50. [Abstract] [PDF]

				P. F. Hu, Y. Xiao, D. Ho, C. F. Mackenzie, H. Hu, R. Voigt, and D. Martz Advanced Visualization Platform for Surgical Operating Room Coordination: Distributed Video Board System Surgical Innovation, June 1, 2006; 13(2): 129 - 135. [Abstract] [PDF]