Title: Parenting Plays Key Role in Infant's Response to Stress
Category: Health News
Created: 9/19/2008 2:00:00 AM
Last Editorial Review: 9/19/2008
So is there a solution?
You see the surgeon several days later, but your medical records have not yet arrived. Instead of rescheduling your appointment, the surgeon scans your leg with an RFID receiver and gets your medical record number. You authorize immediate release of the medical records and your surgeon schedules surgery.
You are admitted to the hospital and the first human error occurs as your healthy leg is entered into the medical record as requiring surgery.
Think about modern surgery. You, the patient, are moved to an operating room. Your identification band confirms that you are the patient scheduled for surgery.
In 1991, a major medical training hospital made the national news after the wrong leg was amputated twice in one week. Despite an abundance of care two unfortunate people entered the hospital expecting to lose one leg and walk out with a prosthesis and ended up loosing both legs and leaving in a wheelchair.
You are moved to the operating room. Your identification band confirms that you are the patient scheduled for surgery. Once the operating room staff ensures you are you, the site of surgery is confirmed in the chart and marked. You may even be asked to confirm that they are marking the correct spot. The chart indicates your healthy leg is the surgery site. You have already received medication and agree as a result of the sedation.
This is the first possible point of error, wrong name on the surgery schedule.
In 1999, the Institute of Medicine published a landmark report on patient safety titled: To Err is Human and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) began championing the cause of patient safety and the prevention of wrong site surgery. Over the past 16 years, hospitals, doctors, nurses and many, many others have developed and implemented procedures designed to stem the rising tide of tragic errors.
The surgeon arrives and prepares to begin cutting when the final RFID chip scan is performed. No RFID chip can be found in the leg about to be amputated. The surgery team immediately removes all the surgical drapes and scans your diseased leg. The RFID chip is found and the correct leg is washed, prepped, draped and amputated.
This is an opportunity to reinforce prior error by eliminating the ability of the surgeon to recheck each of the above steps easily.
Tragedy averted!
RFID chips are biologically inert and implanted through a small needle as easily as giving an antibiotic shot. These are the ideal characteristics for a wrong site surgery solution.
To Err is Human RFID may be Divine
Once your healthy leg is marked, your healthy leg is washed and prepped further entrenching this as the correct side. Then your entire body is covered by surgical drapes and other items that reduce you to an unidentifiable pile of cloth with a small window of skin.
Technology has the solution. Implantable RFID chips are currently in use as unique medical record identifiers for patients and disaster responders world wide. Contrary to popular myth, there is no GPS tracking system or other privacy issue created by these passive electronic numbers.
Once your surgery site is marked, you receive medication (if you didnt earlier). Your surgery site is washed and prepped further entrenching this as the correct side. Then your entire body is covered by surgical drapes and other items that reduce you to an unidentifiable pile of cloth with a small window of skin.
In 2007 at a conference on patient safety, the CEO of JCAHO disclosed that despite tremendous effort, expense and study, the number of wrong site surgeries has risen unabated and exponentially since 1991. Every attempt to change this horrific reality has failed!
Impossible?
Perhaps, imagine if you could mark the surgical site days or even weeks before surgery without risk of changing the marking. Imagine a pre-operative marking system that provided a unique identifier for the surgical site that is not affected by the process of washing, prepping and draping. Imagine a patient and surgical identifier that can be checked repeatedly from the point of admission through the pre-operative procedure, during the operation and even after the correct limb were amputated.
This is the next possible point of error, wrong site listed in the chart or told to you.
The day of your surgery, the second human error occurs as your roommate is moved to the operating room. Instead of amputating the wrong leg from the wrong person, your roommate is scanned for an RFID chip and the unique identifier reveals that you and your roommate received the same wristband.
How can this be?
The surgeon arrives and prepares to begin cutting. The surgeon confirms that you were identified and the correct surgical site was marked. The amputation is completed and the surgery team removes the surgical drapes and discovers your diseased leg was NOT amputated!
The title of the 1999 report summed it up: To Err is Human.
Once the operating room staff ensures you are you, the site of surgery is confirmed in the chart and marked. You may even be asked to confirm that they are marking the correct spot.
No More Wrong Site Surgery
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