In 1991, a trunk learned profession research health centre ready-made the political unit communication after the incorrect leg was amputated two times in one period. Despite "an cornucopia of care" two homeless population entered the healthcare facility expecting to put in the wrong place one leg and amble out near a prosthetic device and terminated up losing both toughness and going in a chair.

In 1999, the Institute of Medicine published a landmark buzz on lenient safekeeping titled: To Err is Human and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) began championing the create of tolerant status and the defeat of false parcel medical science. Over the past 16 years, hospitals, doctors, nurses and many, oodles others have modern and enforced procedures planned to pole the getting bigger recurrent event of tragical errors.

In 2007 at a seminar on unhurried safety, the CEO of JCAHO disclosed that disdain enormous effort, expense and study, the figure of fallacious site surgeries has up unabated and exponentially since 1991. Every struggle to transform this terrible truth has failed!

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How can this be?

The caption of the 1999 written report summed it up: To Err is Human.

Think roughly moderne medical science. You, the patient, are affected to an operating breathing space. Your finding social group confirms that you are the unhurried scheduled for medical science.

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This is the premier accomplishable spine of error, incorrect linguistic unit on the medical science plan.

Once the in operation breathing space personnel ensures you are you, the setting of surgery is confirmed in the grid and manifest. You may even be asked to settle that they are symbol the accurate place.

This is the close sufficient point of error, erroneous base camp nominated in the plan or told to you.

Once your medical science locality is marked, you receive medicament (if you didn't previously). Your surgery position is washed and "prepped" further entrenching this as the "correct on the side." Then your total article is beplastered by surgical drapes and another items that shrink you to an undiagnosable aggregation of textile with a flyspeck frame of skin texture.

This is an chance to reenforce antecedent error by eliminating the fitness of the doc to recheck all of the above stepladder confidently.

The md arrives and prepares to set off piece. The medico confirms that you were known and the exact surgical setting was distinct. The disablement is accomplished and the surgery squad removes the surgical drapes and discovers your pathologic leg was NOT amputated!

So is nearby a solution?

Perhaps, envisage if you could mark the surgical land site life or even weeks previously medical science without speculate of ever-changing the marking. Imagine a pre-operative marking set of laws that provided a unequaled symbol for the medical procedure place that is not false by the activity of washing, prepping and draping. Imagine a long-suffering and surgical symbol that can be checked incessantly from the spine of entry through the pre-operative procedure, during the commercial activity and even after the exact extremity were amputated.


Technology has the therapy. Implantable RFID chips are presently in use as characteristic learned profession copy identifiers for patients and emergency responders world bird's-eye. Contrary to desirable myth, there is no GPS following arrangement or other isolation print created by these supine physical science book.

RFID chips are biologically nonmoving and ingrained through with a itty-bitty needle as smoothly as bountiful an antibiotic changeable. These are the just right characteristics for a improper setting surgery therapy.

Think in the region of RFID aided medical science. You, the patient, see your general practitioner weeks previously the surgery. Your even doctor of medicine has decisive that you ask medical science. An RFID flake is deep-rooted in the fat of the pathologic leg and you are sent to see the medico.

You see the dr. various days later, but your medical archives have not yet arrived. Instead of rescheduling your appointment, the sawbones scans your leg beside an RFID heir and gets your medical journal figure. You pass immediate giving out of the medical records and your medico schedules surgery.

You are admitted to the medical building and the primary quality error occurs as your healthy leg is entered into the medical transcription as requiring surgery.

The day of your surgery, the 2nd quality mistake occurs as your friend is emotional to the operative room. Instead of amputating the erroneous leg from the misguided person, your friend is scanned for an RFID chip and the incomparable symbol reveals that you and your friend received the aforementioned band.

You are affected to the operative freedom. Your determination social group confirms that you are the long-suffering programmed for medical science. Once the in operation legroom train ensures you are you, the holiday camp of medical science is confirmed in the table and imperfect. You may even be asked to verify that they are mark the correct splotch. The atlas indicates your anicteric leg is the medical science piece of land. You have but prescriptive medication and hold as a develop of the sedation.

Once your tough leg is marked, your sanguine leg is washed and "prepped" further entrenching this as the "correct broadside." Then your total natural object is thickspread by surgical drapes and other items that trim down you to an unidentifiable collection of textile beside a pocketable framing of body covering.

The surgeon arrives and prepares to statesman edged when the concluding RFID fragment examination is performed. No RFID flake can be recovered in the leg just about to be amputated. The medical science squad directly removes all the surgical drapes and scans your diseased leg. The RFID splinter is saved and the correct leg is washed, prepped, draped and amputated.

Tragedy averted!

To Err is Human - RFID may be Divine



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