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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


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