Winter 2004 - 2005
Safety Innovation in the Operating Room of the Future
by Tod Brubaker
Inside the control room of OR49 at the Massachusetts General Hospital,
an alert sounds. Hurrying to one of the room's many computer screens,
a physician sees a luminous dot where it shouldn't be. This discrepancy can only mean one thing: A patient has been brought to the wrong operating room. Upon investigation it seems that two anesthesiologists
unwittingly triggered the alert. As a result of a backlog that tied up their assigned Operating Room (OR) - an event that frequently plagues hospitals - the doctors temporarily parked their patient in front
of another OR while they carried out pre-anesthetic procedures. When the correct OR was finally cleared, they whisked the patient inside as scheduled.
For the staff of OR 49, otherwise known as the Operating Room of the
Future (ORF), identifying this potentially fatal problem is further proof that the newly deployed technology works. "We have conducted
hundreds and hundreds of trials under controlled circumstances,"
said Warren Sandberg, M.D., Ph.D., anesthesiologist and co-program
leader for the OR of the Future Project. "It has never failed."
The Zone of Safety
The false alarm that occurred in OR 49 is not
technically considered to be an error. However, it served to provide important evidence that the automated system is functioning appropriately. This type of alert has the potential to save countless lives throughout American healthcare facilities. The Institute of
Medicine (10M) has estimated that as many as 98,000 Americans die in
hospitals each year as a result of preventable medical errors. If so, that would make medical errors the eighth leading cause of death in the United States, ahead of motor vehicle accidents, breast cancer, and AIDS.
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