Wireless technology

RFID wristbands track patients safely through surgery

Wrong side/site surgery (WSS) is known to be a major cause of morbidity and litigation in the Health Service. However, costly mistakes and errors continue to occur across the UK. In 2006/7 clinical negligence claims against the NHS in the UK were in excess of £600 million, and the total potential liability stood at over £9 billion.

Patient misidentification is one of the key causes of mistakes and a recent ten-month survey by the National Patient Safety Agency found that misidentification was the cause of 22% of 44 WSS incidents found in 28 sites. Further, the government estimates that errors associated with mistaken identity cost the NHS approximately £2 billion in extra bed days.

Identification of the patient, operation and side is often dependent on a manual system that is fraught with problems. A common cause of WSS is the last-minute change made to a written operating list, causing confusion and mistakes.

The birth of a new system

As a consultant surgeon, I have direct knowledge of a mistake made in a surgical specialty in my hospital, resulting in a child having the wrong operation, which is why I developed the concept of the Safe Surgery System. RFID technology enabled us to develop a simple yet sophisticated application that provides a real solution to a very real problem — for patients as well as for the NHS.

The system uses radio frequency identification (RFID) tags that are embedded in wristbands to identify and track patients. It can even control the theatre process in a way that ensures that all the manual checks are carried out prior to allowing the patient to move to theatre for surgery.

An RFID wristband emerging from a printer

We wanted to take advantage of the latest technology to set new standards for patient safety and improve the efficiency of our operating theatres.

We rely on patients’ wristbands to equip us with the right information to provide every aspect of their treatment, from administering medication and transfusing blood to carrying out surgical procedures. Given its critical role in patient care, any system we developed had to be based around the RFID wristband as barcodes were proving to be unreliable and difficult to use.

Managing the theatre process

On admission to the surgical ward the patient is photographed and given a printed wristband with an embedded RFID tag. The patient’s digital image is part of the patient record and used to further verify identity.

The surgeon, anaesthetist and ward nurse each have a wireless PDA, which allows them to view the operating list and each patient record. When the clinician approaches the patient with their PDA, they can use the embedded photograph to identify the patient, or scan the RFID tagged wristband. The patient’s pre-operative checks are then recorded on the PDA, which immediately updates their status on the operating theatre list.

The author with a patient, checking data on a PDA

The same theatre list is visible on workstations in the ward, anaesthetic room, theatre and recovery area, and a ‘traffic light’ warning system, which changes from red to green in the patient record, is used to ensure all the required checks have been performed before surgery commences.

When patients are sent to theatre, the RFID scanner recognises them from their tag and retrieves the appropriate record on the screen with their planned procedure, ensuring there is no opportunity for misidentification.

Theatre efficiency is automatically measured as each step in the process is recorded with a time and date stamp. Also, the surgical procedures (which are specially coded) are checked or amended by the operating surgeon to improve efficiency, financial return and further cut administration time.

The pilot

In November 2004, Birmingham Heartlands Hospital, part of The Heart of England NHS Foundation Trust, undertook a proof of concept trial of the system in one theatre and a ward for 12 months. As the trial proved that there were both patient safety and theatre efficiency benefits to be gained, a business case was prepared for a phased roll out of the system in all theatres in the trust.

The case was based on the cost benefits arising from increasing the number of patient theatre procedures per theatre session, improving the accuracy of clinical coding and other savings including label stationery and administration staff time.

From the proof of concept trial it was clear that these were achievable and would be measured more accurately during the first phase of the rollout. Thus the business case was approved and the invitation to tender for the supply contract published in the spring of 2006.

The rollout

Once the contract was eventually awarded to Safe Surgery Systems, implementation started in January 2007 in all the wards and theatres used by two surgical specialties. The implementation required additional hardware and infrastructure, integration with the trust patient administration and theatre booking systems and, of course, the education and training over 130 clinicians, ward and theatre staff.

To make matters more complicated, the project was concurrent with two other trust projects; installation of a new wireless LAN throughout the hospital and the integration of core systems within the newly merged trust.

In March 2007 the system went live despite two ward reconfigurations and the usual hardware and communications teething problems and useful lessons were learned about implementing totally new technology into the theatres and wards. For example, plans had to be altered to facilitate user adoption by providing additional help and guidance to users for the first few weeks and to display single-sheet user guides at each workstation.

In addition, now that the system was being used by a much larger community of users, a number of software changes were implemented to enhance its usability and functionality.

User reaction

A user survey was conducted by the Trust to determine the success of implementation from a staff perspective and identify potential hurdles to overcome. The returned questionnaires showed that the system scored 62% for ease of use and satisfaction. Overall, respondents were relatively satisfied with each aspect of the system, with theatre staff the most pleased with the system.

At an early stage in the implementation it became clear that the concurrent use of the existing paper system and the IT system reduced compliance and this will need to be addressed by the directorate management in due course. This duplication of systems (paper and computer) has had a similarly detrimental affect on the adoption of technology within the NHS as a whole and thus it was not surprising.

From a usability point of view, RFID tagged wristbands have the benefit of being read-through material and being read generally first time. The former is important from a patient respect point of view (as opposed to having to expose the patient wristband and move it around to find a readable bar code). The latter ensures that staff are not frustrated by failed read attempts.

In order to evaluate the use of the system in the two specialties at the Heartlands Hospital, the trust performance department carried out comparative reporting (before and after go-live of the Safe Surgery System) and the results have been very encouraging.

Patient safety assured

In a five-month period after the system went live, four patient safety incidents were identified and blocked, any of which could have led to an adverse event. The system blocked patients going to the wrong theatre and identified some as not fit for surgery due to the electronic checking process. Thus the system has proved its potential to mistake-proof the surgical journey and to reduce potential litigation costs to the trust.

Increased theatre efficiency

Analysis from the trust performance department for the specialties using the system showed that the average cases per theatre session for all consultants had increased by nearly 12%, while the top five performing consultants had increased their cases per session by nearly 24%. Therefore the system was proving that its workflow management was producing results.

The next stage of analysis, given the real-time data collected by the system, will show more accurately where the theatre process can be further improved. Further clinical coding improvements should also result as the consultants check their procedure codes at time of surgery.

Given the brief time the system has been in use, the first signs show that it can have a positive effect on patient safety and theatre efficiency. The project has been good for Trust PR, receiving support and commendations from the Department of Health, National Patient Safety Agency and the Patients Association, establishing the Trust as a beacon site for patient auto-identification.

RFID as a means of identification has proved itself to be a useful benefit and the Trust are considering its use as a ubiquitous means of patient identification with the potential for other UK NHS trusts to rollout the system.

David Morgan FRCS, Consultant Surgeon, Heart of England NHS Foundation Trust, Birmingham, UK.