Wrong Site Surgery

My hospital has recently installed a new Theatre Management System (TMS).  It is not a CSC system.  On two occasions in the last month, the wrong patient has been brought to my anaesthetic room.  The errors were quickly noticed and the patient redirected correctly.  This is the first time, in 20+ years’ practice that I can recall this happening, though it is a well-known cause of wrong site surgery

There are ongoing root cause analyses, but I suspect an underlying factor is that we have no reliable way of identifying the patient or the location. 

RFID technology exists that could address this issue.  Perhaps if the patient had been wearing an RFID bracelet, and there were sensors in the doors, such a mistake would not occur.  If such a system were linked to the TMS, maybe it would be foolproof? 

You will be a patient yourself one day and your safety could depend on it!


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