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\title{Modeling And Implementing RFID Enabled Operating Environment For Patient Safety Enhancement}
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             \author[1]{Dr. Chuan-Jun  Su}

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\date{\small \em Received: 13 February 2010 Accepted: 4 March 2010 Published: 15 March 2010}

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\begin{abstract}
        


Patient safety has become a growing concern in health care. The U.S. Institute of Medicine (IOM) report ?To Err Is Human: Building a Safer Health System? in 1999 included estimations that medical error is the eighth leading cause of death in the United States and results in up to 100,000 deaths annually. However, many adverse events and errors occur in surgical practice. Within all kinds of surgical adverse events, wrong-side/wrong-site, wrong-procedure, and wrong- patient adverse events are the most devastating, unacceptable, and often result in litigation. Much literature claims that systems must be put in place to render it essentially impossible or at least extremely difficult for human error to cause harm to patients. Hence, this research aims to develop a prototype system based on active RFID that detects and prevents errors in the OR. To fully comprehend the operating room (OR) process, multiple rounds of on site discussions were conducted. IDEF0 models were subsequently constructed for identifying the opportunity of improvement and performing before-after analysis. Based on the analysis, the architecture of the proposed RFID-based OR system was developed. An on-site survey conducted subsequently for better understanding the hardware requirement will then be illustrated. Finally, an RFID-enhanced system based on both the proposed architecture and test results was developed for gaining better control and improving the safety level of the surgical operations.

\end{abstract}


\keywords{Radio Frequency Identification (RFID), Patient  Safety, Operating Room, IDEF0.}

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\let\tabcellsep& 	 	 		 
\section[{I. INTRODUCTION}]{I. INTRODUCTION}\par
he Operating Room (OR) briefing is a tool to enhance communication among the team members of operating room and improve patient safety \hyperref[b0]{[1]}, which is the most important and uncompromised issue for medical institutions. It has become a growing concern in health care. As expected, many adverse events and errors occur in surgical practice. Taking the correct patient into the correct OR and executing correct procedures by correct medical staff have become widely understood as the fundamental infrastructure of safe patient care to avoid adverse events in the operating room. Hence, there are four critical requirements to give the right treatment to the right patient: i. Correct patient ii.\par
Correct OR iii.\par
Correct medical staff iv.\par
Correct operations Whether wrong patient, wrong location, wrong medical staff or wrong operation event has resulted in injury or didn't raise actual harm, those kind of events cause anxiety for patients and staff, disrupt the smooth flow of patients through the OR suite, and increase the probability of medical errors. Hence, this research aims to develop a prototype system based on RFID that detects and prevents errors in the OR. The system provides hospitals to correctly identify surgical patients and track their operations to ensure they get the correct operations at the right time.\par
II. 
\section[{LITERATURE REVIEW}]{LITERATURE REVIEW}\par
Patient safety means minimizing harm to patients arising from medical treatment \hyperref[b1]{[2]} and is becoming a growing concern in health care. There are many factors involved in patient safety today, and there are many factors to consider when improving the safety process \hyperref[b2]{[3]}. Recent attention to this topic stems from several high-profile medical errors and several Institute of Medicine (IOM) reports which quantified the problem, created standardized definitions, and charged the healthcare community to develop improved hospital operating systems \hyperref[b3]{[4,}\hyperref[b4]{5]}.\par
The operating room (OR) is one of the most complex work environments in health care. Compared with other hospital settings, errors in the operating room can be particularly catastrophic and, in some cases, can result in high-profile consequences for a surgeon and an institution. In addition, the high rate of adverse events in surgery is incessantly demonstrated. According to a sentinel event alert issued  {\ref Dec 5, 2001}, by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "fifty-eight percent of the cases occurred in either a hospital-based ambulatory surgery unit or freestanding ambulatory setting, with 29 percent occurring in the inpatient operating room and 13 percent in other inpatient sites such as the Emergency Department or ICU. Seventy-six percent involved surgery on the wrong body part or site; 13 percent involved surgery on the wrong body part or site; and 11 percent involved the wrong surgical procedure" \hyperref[b5]{[6]}. After the astonishing report published by  {\ref JCAHO Gawande et al., in 2003}, analyzed errors reported by surgeons at three teaching hospitals and found that seventy-seven percent involved injuries related to an operation or other invasive intervention (visceral injuries, bleeding, and wound infection/dehiscence were the most common subtypes), 13\% involved unnecessary or inappropriate procedures, and 10\% involved unnecessary advancement of disease. In addition, two thirds of the T incidents involved errors during the intra-operative phase of surgical care, 27\% during pre-operative management, and 22\% during post-operative management \hyperref[b6]{[7]}. In other words, no matter how well-trained a medical staff is, he or she could still make mistakes. Within all kinds of surgical adverse events, wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) are the most devastating, unacceptable, and often result in litigation. However, an estimate of 1300 to 2700 WSPEs per year based on the available databases, extensive review of the literature, and discussion with regulators in the United States seems likely \hyperref[b7]{[8]}. A variety of studies have demonstrated that the rates of adverse events associated with surgery are substantial. Of course, surgery inherently carries risk, and only 17 per cent of these adverse events were judged to be preventable \hyperref[b8]{[9]}. Nonetheless, this important proportion of surgical adverse events is preventable given what is known today. Systems must be put in place to render it essentially impossible or at least extremely difficult for human error to cause harm to patients. With the introduction of new approaches many other complications that are not associated with an obvious error may be preventable in the future.\par
III. 
\section[{REQUIREMENT STUDY}]{REQUIREMENT STUDY}\par
As mentioned in the previous chapters, the high rate of sentinel events in surgery has been incessantly demonstrated. Among all sentinel events, performing a procedure on the wrong site or the wrong patient is mostly preventable and should never happen. Much literature claims that systems must be put in place to render it essentially impossible or at least extremely difficult for human error to cause harm to patients. Among a lot of novel technologies, RFID is an enabling technology that is generally considered to improve patient safety and savings in hospital. This technology has been applied for many fields but few applications specified to OR. Moreover, little literature analyzed from the business processes' point of view to reap the benefits of RFID but focus on an object or an individual. Therefore, we proposed using RFID from the processes' point of view to detect errors that may lead to wrong site or the wrong patient surgery. Before an RFID implantation, opportunity survey based on business process analysis is necessary. The survey consists of the following phases: Expert interview and site survey-Expert interview and site survey have conducted to comprehend the process in OR.\par
Existing OR Process: Based on the result of expert interview and site survey, we described the existing OR process. IDEF0 modeling-: IDEF0 modeling technique is adopted to (1) build the OR as-is model based on the result of previous step, \hyperref[b1]{(2)} analyze the activities in the previous OR process. 
\section[{RFID-based OR Process:}]{RFID-based OR Process:}\par
Based on the results of previous steps, we described an RFID-based state for the process. 
\section[{A. Expert Interview and Site Survey}]{A. Expert Interview and Site Survey}\par
Before an RFID implantation, opportunity survey based on business process analysis is necessary. This experience can also be applied in a hospital. Surgeons, nurses and anesthetists are the experts who know what happens behind the closed doors of the operating department. They clearly know their job functions and workflow during surgery. For this reason, we undertook several expert interviews with the medical staff worked in an operating department of a regional teaching hospital in Taoyuan to comprehend the operative process. Except expert interviews, we also perform site survey to observe the activities in OR.\par
The activities during on-site survey include observation of nursing work, review related forms and face-to-face meeting with nurses to capture the entire workflow in OR. The results of expert interviews and on-site survey are described in the following sections. 
\section[{B. Expert Interview And Site Survey}]{B. Expert Interview And Site Survey}\par
The scope of OR process for an individual patient which we describe as follows begins with the surgical patient's arrival at the OR suite and ends when the patient leaves the OR suite. The details of the OR process is shown below: Admission into operating suite-Base on operations schedule, the transporter brings scheduled surgical patient from ward to the operating suite, along with his/her medical record and related document. Upon the patient's arrival in the holding area of operating suite, the holding area nurse orally identifies patient by matching the replies from the patient about the name, ID card number, type of surgery with medical record, etc. After the confirmation, the nurse reviews the document accompanying the patient to check whether the operation related forms such as operative consent form has been completely filled in or not. The patient's national health insurance card is then received by the nurse. After a series of admission procedure, the nurse logged on to the hospital information system to change the patient's status. At the same time, the patient's status information -Wait ing for surgery? is displayed in the screen located in the waiting area to reduce anxiety patient's family members.\par
Admission into operating room-The surgical patient stays in the pre-operative holding area until the OR is ready. However, before a circulating nurse takes a patient into scheduled OR, the nurse verbally identifies the patient again and changes the patient's status from -W aiting for surgery -t o -I n surgery?.\par
Beginning of anesthesia-The anesthetist verbally confirms the patient's identification, type of surgery and part of surgery before anesthesia. If the information is correct, the anesthetist signs in the nursing records of patients' operations. Although the doctor has already determined the anesthetics and methods of delivery before surgery, the anesthetist can make the final decision depending on the patient's specific condition at that point of time. The anesthetist verbally asks the patient's information such as the history of allergy, family history in the OR to decide which kind of anesthetics he or she should use. Besides, anesthesia staff also reviews the anesthesia information and laboratory test data in medical record to assist determining the way to induce anesthesia is suitable for the patient or not.\par
Surgery-A surgeon also has to confirm the patient's identification before surgery. However, the surgical patient is usually covered with surgical drapes and has been anesthetized when a surgeon enters the OR. The surgeon can only justify the patient by medical record or pictures such as X-ray pictures. In the case that the patient was not covered with surgical drapes, the surgeon verifies patient by face.\par
Because surgeons often meet surgical patients before surgery, the surgeons consider that they can distinguish a right patient from a wrong patient by their memory. Before performing an operation, the surgeon refers to the patient's medical record to make sure the surgical procedure and the site of operation. During surgery, surgeon can refer to medical record for the anesthesia information, patient information, results from laboratory information system if necessary. In the operating room information about the location of equipment had direct and sometimes critical implications for patients' clinical outcomes \hyperref[b7]{[8]}.\par
Admission to recovery-After surgery the patient is takes into recovery rooms to wait for "awakening" from anesthesia. At the same time, the nurse in the recovery room changes the patient's status to? In recovery?.\par
Discharge from operating suite: After a patient becomes conscious, the transporter takes the patient back to his/her ward and change patient's status information to -R eturn ward?. 
\section[{C. IDEF0 Modeling}]{C. IDEF0 Modeling}\par
After in-depth understanding of the current process in OR an IDEF0 model was developed. The IDEF0 model is used to help organizing the analysis of OR system and to promote good communication between the analyst and the medical staff. For better understanding of the sequence, we chose sequential form of breakdown which decomposes the parent activity by a sequence of sub-activities to build our system. However, the structure imposed by the IDEF0 methodology naturally creates a set of questions that must be asked and answered about each function and its sub-functions. The answers to these questions provide important information concerning how known human fallibilities which may lead to errors. Thus, we can clarify many activities during model development stage by discussing with medical staff. In this section, first, we built the -as -is? model to define activities and functions in OR. The definition of -as -is? is a description of the current situation in terms of the work processes. With sufficient information regarding the as-is operation, analyzing current process and building a new system become easier. Second, we examined the model, found out the operations which probably threaten to patient safety or make medical staff ineffective and analyzed the opportunity for introducing RFID to solve the problem. 
\section[{D. Building "as-is" Model}]{D. Building "as-is" Model}\par
After expert interviews and on-site survey, the OR as-is model was constructed. The purpose of this model is to find out the systemic vulnerabilities that may lead to human error and the opportunities that can improve medical staff's operations by introducing RFID technology. The model was developed from the OR medical staff's viewpoint. Fig.  {\ref 1} depicts the top-level function of the IDEF0 model, -perfo rm surgery?. The activity called -perf orming surgery? is broadly defined as all activities during per-, intra-and post operations. Fig.  {\ref 2} shows the top-level function decomposed into six more specific functions, representing the surgery process in more detail. Note that the general inputs, outputs, controls, and mechanisms from Fig.  {\ref 1} are also decomposed, illustrating the progressive exposure of detail that is a feature of the IDEF0 methodology; Fig.  {\ref 3} shows the decomposition of the activity -pati ent check-in? at an even higher level of detail. In the same way, Fig.  {\ref 4}, 5 and 6 shows the decomposition of the other activities in detail. 
\section[{E. As-is Model Analysis and RFID Solutions}]{E. As-is Model Analysis and RFID Solutions}\par
In the operating room information about the location of equipment had direct and sometimes critical implications for patients' clinical outcomes \hyperref[b9]{[10]}. After building the OR as-is model and numbers of meeting with related medical personnel, we discovered that there were a lot of systemic vulnerabilities that may lead to human error. In real situations, not every OR member completely follows the Standard Operating Procedures (SOP). If some accidental situations happen, wrong patient, wrong site/side surgery, unsuitable anesthesia or wrong OR event may occur. Based on the as-is model, the possible human errors and inefficient operations are listed as follows:  Inducing unsuitable anesthesia-An anesthetist has to make the final decision regarding the anesthetics and methods of delivery at the time of surgery. Therefore, providing sufficient information to the anesthetist is very important. In general, the critical information that aids an anesthetist making decision must be obtained from both ways: verbally asking the patient and reviewing some data described in the medical record. The questions now arise: first, some critical information even was not recorded in a patient's medical record. History of allergy and family history, for example, only can be received by asking patients. If the patient is not conscious or too elderly to answer the questions from medical staff, it would cause the patient to be exposed to danger. Second, looking for the unfiltered data on the paper is inefficient to anesthesia staff. Performing wrong operations-Wrong operation mentioned here includes performing wrong procedures on a patient or perform a surgery on the wrong site/side of a patient's body. Based on the as-is model, the doctor conforms patient's operation-related information by checking the patient's medical record and surgery-site chart that describes the surgical site/side of a patient. However, because it is not convenient to find out disperse data by looking up the paper-based medical records, doctors sometimes depend on their memory for patients' condition without double-check. In addition, when a surgeon substitutes for another surgeon to perform a surgery or a surgeon operates on more than one patient at the same time, the wrong operation may be performed.\par
Inefficiently updating patient"s states-Based on the as-is model, nurses have to manually update a patient's status information (in surgery, in recovery, etc.) in the hospital information system when the patient's status is changed. However, the essence of the OR nurses is to provide care and support to patients before, during, and after surgery. This kind of unrelated activity distracts medical staff and obstructs medical professionals providing better patient care. -Wrong Procedure A42 Passive and inconvenient confirmation processes do not encourage medical staff to reconfirm patient's information. A substitute surgeon is not familiar with the surgical patient.\par
A surgeon operates on more than one patient simultaneously.\par
-Wrong Anesthesia A41 A patient who is not conscious or too elderly to answer the questions from medical staff causes that some critical information can not be obtained.\par
It is inconvenient to look for dispersed and unfiltered information.\par
-Inefficient Operations A15, A23, A5, A6 Wasting time to update patients' status information in the computer obstructs medical professionals providing better patient care.\par
As mentioned above, not every OR member completely follows the SOPs in real situations. Therefore, if some accidental situations happen, wrong patient, wrong site/side surgery, unsuitable anesthesia or wrong OR event may occur. Table1 shows potential cases that may threaten patient's safety in the as-is model. Human error is inevitable and unavoidable. However, most preventable adverse events are not simply the result of human error but are due to defective systems that allow errors to occur or go undetected. Therefore, we propose an RFID-based OR system that can reinforce SOP and prevent potential errors for achieving the ultimate objective of improving patient safety in OR. The proposed RFID-based OR system is expected to complement current human-based operations in the following ways: Patient Identification-Improving the accuracy of patient identification is one of JCAHO 2006-2007 patient safety goals which suggest using active communication technique to conduct final verification process and using at least two patient identifiers. However, either suggestion was not adopted in the "as-is" process. The problem can be solved by introducing RFID that can automatically identify patients to complement current human-based verification. Surgical site verification-To decrease the incidence of wrong site/side surgery, we have developed a digital chart of surgery site marking which can be displayed on the LCD monitor of OR. By integrating RFID with hospital information system (HIS), the digital chart and some critical information of the patient are automatically shown on the monitor when the patient is brought to the scheduled OR.\par
OR verification-If a patient is brought to an unscheduled OR, the system will create a warning on the monitor. Thus, the RFID-based system checks the wrong-location event to prevent the potential wrong surgery.\par
Patient status update-The activity of updating patient's status distracts medical staff from surgery related tasks. In the developed RFID-based system, the status will be updated automatically by integrating RFID with the backend HIS. 
\section[{F. RFID-enabled OR Process}]{F. RFID-enabled OR Process}\par
After analyzing as-is model, we have developed an RFIDbased prototyping system that detects and prevents errors in the OR. The system provides hospitals to 1) correctly identify surgical patients, 2) track the ORs in which patients and medical staff enter, and 3) furnish critical information to ensure patients get the correct operations at the right time and place. The "to-be" RFID-based OR process derived from analyzing the "as-is" model is illustrated as follows:\par
Admission into the operating suite-When a surgical patient is scheduled to be operated upon, the nurse in the ward assigns the patient an RFID-embedded wristband encoded with a unique ID. When the surgical patient is brought to the holding area in the OR suite, an RFID reader automatically verifies the identity of the patient. If the details of the patient and operation schedule match, the monitor in the holding area displays some brief information about the patient. Simultaneously, the system automatically changes the patient's status information to -wait ing for surgery? in the database. Then, the patient's status information can be displayed on the screen located in the waiting area that it can helps in reducing the anxiety of his/her family members.\par
Admission into operating room-The RFID readers in the OR automatically capture the information on the patient's tag to identify him/her upon entering the OR. If the details of the patient and the OR into which he/she has entered match, the screen in the OR displays the patient's information, including his/her name, age, gender, laboratory test data, digital surgery-site chart, and scheduled procedure, by associating the tag's ID number with the patient records stored in the hospital information system. However, if an unscheduled patient enters the OR, the system can alert the medical staff to take the necessary measures in the OR. Thus, unfamiliar faces can be checked with assurance, thereby decreasing the probability of performing the procedure on a wrong patient. Subsequently, the system automatically changes the patient's status information to -i n surgery? after confirming that the correct patient has entered the correct OR. In addition, because the time is automatically recorded, the medical staff does not have to record the time manually. Thus, unfamiliar faces can be checked with assurance, thereby decreasing the probability of performing the procedure on a wrong patient. Subsequently, the system automatically changes the patient's status information to -i n surgery? after confirming that the correct patient has entered the correct OR. In addition, because the time is automatically recorded, the medical staff does not have to record the time manually. Initiation of anesthesia: When a tagged anesthetist or nurse enters the room, the system will also ensure that the person has entered the right room, thus preventing medical staff from rushing into the wrong OR and administering inappropriate medical treatment. In addition, information such as the history of allergy, family history, and laboratory test data, which aids the anesthetic team in determining the appropriate anesthetics and method of administration, is displayed on the monitor when the anesthetic team enters the OR. Furthermore, any abnormal values will be marked in red to bring them to the medical staff's attention. Surgery-In the same manner, when a surgeon enters the room, the system will also check whether the person has been assigned to the room, in order to prevent doctors from entering the wrong OR and performing surgery on the wrong person. If the patient has not yet been covered with surgical drapes, the surgeon can reconfirm the patient's identity by matching the patient with a photograph displayed on the screen. In addition, the surgeon is also provided with the patient's critical information on the digital display, rather than having to search for the pertinent information in the documented reports. Thus, bringing all this information together not only saves time but also increases patient safety. The surgeons are encouraged to confirm the patient records through the centralized data displayed on the monitor because of this increased accessibility. In the absence of such a system, doctors would generally depend on their memory, without performing any reconfirmation due to the inconvenience involved.\par
Transfer to recovery-After surgery, patients are transferred to the recovery area. Here, the RFID readers detect the patient's RFID tags and the system automatically changes the patient's status to -i n recovery.? Discharge from operating suite: After a patient recovers from anesthesia, the transporter brought the surgical patient leaving recovery room and returning to ward. At this time, the system automatically updates the patient's status information to -returne d to ward.? IV. 
\section[{THE ARCHITECTURE OF RFID-BASED OR SYSTEM}]{THE ARCHITECTURE OF RFID-BASED OR SYSTEM}\par
Beside on the result of the previous section, we proposed an architecture of the RFID-based OR system. The architecture of the RFID-based OR system consists of 1) physically distributed RFID readers, tags, 2) an RFID server that processes the data from the readers, 3) several client PCs that run different hospital applications, and 4) the hospital information system (HIS) that plays the same role as that of an ERP system in enterprise-level architectures. The RFID server contains a backend database and software called the concentrator that receives the data from RFID readers when the tags are detected. Then, the concentrator checks this data for errors and stores it on an operational database. In our architecture, the concentrator also communicates with other software that implement the application's business logic on client PCs. In addition, the RFID server is connected to the HIS to extract hospital data through an intranet. The architecture of this system is illustrated in Fig. \hyperref[fig_1]{7}. In summary, there are five primary components in the RFID-based OR system: (1) Reader, (2) tag, (3) RFID server, (4) client PCs that manage the client-side applications, and (5) the HIS. 
\section[{HIS (Hospital Information}]{HIS (Hospital Information} 
\section[{V. IMPLEMENTATION}]{V. IMPLEMENTATION} 
\section[{A. RFID Hardware Test and Deployment}]{A. RFID Hardware Test and Deployment}\par
A -Sit e Survey? is essential for real RFID implementation.\par
The actual RF coverage, number of readers, their placement and configuration, and system accuracy are greatly dependent on environmental factors. In order to increase the feasibility of the hardware in a clinical environment, we deployed our hardware in an OR suite in a regional teaching hospital in Taoyuan to determine the optimum hardware deployment that fits our test scenario. The test environment was set up in three regions of an OR suite including the holding area, OR-5, and the recovery area. After a series of tests, the result each test scenarios is show as Table  {\ref 2} and the RF coverage as shown in Fig. \hyperref[fig_3]{8}. 
\section[{Table2. Results of Testing}]{Table2. Results of Testing} 
\section[{Test Scenario Goals Results}]{Test Scenario Goals Results} 
\section[{Holding area}]{Holding area}\par
The reader located in the holding area steadily detects the investigator's arrival. The tagged investigator must be detected by the reader located in the recovery area while he/she entered the area. 
\section[{?}]{?}\par
The reader located in the recovery area cannot detect other patients who passed the recovery area on their way to their scheduled ORs. 
\section[{?}]{?}\par
The reader also can't detect a patient who walked on the corridor outside the OR suite. 
\section[{?}]{?}\par
Although part of testing results does not meet our requirement, we can use a system to filter certain unnecessary signals. The solution can be summarized as shown in Table  {\ref 3}. 
\section[{Table3. Solution of Redundant RF Coverage}]{Table3. Solution of Redundant RF Coverage} 
\section[{Location of readers}]{Location of readers}\par
Solution of exceeded RF signalsHolding Area (\textbf{Exception 1)}\par
If a patient who has already been detected by the reader located in the holding area is detected again, the application system executed in the holding area will omit the event to avoid the patient check-in twice. Therefore, the RF coverage can extend beyond the zone of the holding area because the detection of a passerby walking on the corridor in the OR suite will not be processed again. 
\section[{Recovery Area (Exception 2)}]{Recovery Area (Exception 2)}\par
The application system executed in the recovery area supposes a patient who was not detected by any other readers located in the OR suite was a passerby. Hence, if a patient who do not have to undergo an operation passed through the recovery area out of the OR suite and is detected by the reader located in the recovery area, the system will filter the event to avoid mistakenly execute the application.  
\section[{B. Two Different Types Of Scenarios}]{B. Two Different Types Of Scenarios}\par
After RFID hardware test and deployment, we have proposed two different types of scenarios: normal and accidental situations. The scenario of normal situations describes the general process during surgery; the scenarios of accidental situations show the unexpected events that may threaten patient's safety. Those scenarios was demonstrated by our system to describe how the RFIDbased OR system prevents errors and improve patient safety. Scenario 1: Normal situations-Miss Wang (Shiau-ching Wang, a pseudonym) is admitted to the obstetrics and gynecology department of a teaching hospital for surgery. The bed number of Miss Wang is W06-1. The doctor in charge of Miss Wang logged on to the admission application system to enter some surgical information about Miss Wang and to draw the operation site in detail.\par
Based on the operations schedule, the holding area nurse telephoned the obstetrics and gynecology floor, identified herself by name, and asked for Miss Wang to be prepared for the operation. After the phone call, the nurse checked Miss Wang's medical records, logged on to the admission application system, and assigned an RFID wristband to her. After a while, the transporter arrived at the obstetrics and gynecology department and brought Miss Wang from the ward to the operating suite, along with her medical records and related documents. When Miss Wang entered the holding area of the OR suite, the reader grabbed the tag's ID stored in the RFID wristband. Subsequently, the monitor in the holding area displayed brief information about Miss Wang. The screen located in the waiting area outside the OR suite simultaneously displayed the patient's status information as -wait ing for surgery? to reduce the anxiety of the patient's family members. The holding area nurse completed the admission procedure for Miss Wang, after which Miss Wang remained in the holding area waiting for surgery. After a while, the OR was ready for surgery. A circulating nurse took Miss Wang into the scheduled OR-5. While Miss Wang was brought to OR-5, the reader detected Miss Wang's RFID wristband and the monitor located in that OR displayed Miss Wang's personal and surgery-related information. At the same time, the screen located in the waiting area updated the patient's status information as -i n surgery.? An anesthetist, Dr. Chen, entered the OR, and checked the information that would help him make the final decision regarding the anesthetics and methods of delivery. The surgeon, Dr. Lin, entered OR-5 and reviewed the information displayed on the monitor to reconfirm the patient's surgical procedures. Following these checks, the surgery was performed. After surgery, Miss Wang was brought to the recovery area.\par
The readers in the recovery area detected the RFID wristband worn by Miss Wang. Hence, the monitor in the recovery area displayed brief information about Miss Wang. At the same time, the screen located in the waiting area updated the patient's status information as -i n recovery.? After Miss Wang recovered from the anesthesia, the transporter brought her from the recovery room to her ward.\par
While Miss Wang has leaved the recovery room, the screen located in the waiting area updated the patient's status information as -return t o ward.? Demonstration of System Usage Scenario 1-After the decision to perform an operation on Miss Wang, the doctor in charge of Miss Wang logged on to the admission application system (See Fig.  {\ref 9}), pressed the button marked -o peration site mark,? and inputted two identification parameters-the number on the identification card and the bed number-in order to provide some surgical information about Miss Wang and to draw the operation site in detail (See Fig.  {\ref 10} and Fig.  {\ref 11}). After the phone call from the OR, the nurse working in ward 6 checked Miss Wang's medical records, logged on to the admission application system, and assigned an RFID wristband to Miss Wang (See Fig.  {\ref 12}). Miss Wang entered two identification parameters-the number on the identification card and the bed number-to retrieve Miss Wang's information for double-checking. At the same time, the system automatically checked the operation schedule to confirm Miss Wang's operation. After ensuring that Miss Wang was the correct patient whose name had listed in the operation schedule, the system associated the ID stored in the RFID wristband with the patient's identification in the database. After this computerized process, the nurse assigned the RFID wristband to Miss Wang. 
\section[{Fig.12. Assign tag}]{Fig.12. Assign tag}\par
On Miss Wang's arrival in the holding area of the operating suite, the preoperative application associated the tag's ID propagated from the middleware with the patient's identification and checked the patient's identification with the operation schedule. After confirming Miss Wang's identification, the monitor in the holding area displayed brief information about Miss Wang. Subsequently, the system automatically changed the patient's status to -wait ing for surgery? (See Fig.  {\ref 13}). 
\section[{Fig.13. User interface displayed in the holding area}]{Fig.13. User interface displayed in the holding area}\par
While Miss Wang was brought to OR-5, the operative application updated Miss Wang's status to -i n surgery? to inform her family about the progress of the operation. At the same time, the system automatically executed the user interface and displayed some information about Miss Wang including personal information, surgical site, diagnosis, operation description, laboratory test data, etc. to avoid fragmented communication and dispersed information (See Fig.  {\ref 14} and Fig. \hyperref[fig_5]{15}). 
\section[{Fig.14. User interface displayed in the OR-5 I}]{Fig.14. User interface displayed in the OR-5 I}\par
The information displayed on the screen can be separated into three parts: basic patient information (helps identify the patient), operative information (ensures correct procedures), and advanced information (supports anesthesia decision). Basic patient information includes the patient's picture, name, ID card number, medical record number, bed number, blood type, sex, age, and birthday. Operative information includes the diagnosis, operation description, and the anesthesia administered by the doctor. Advanced information contains a history of allergy, information of diseases in the family, chronic prescription medicines, and laboratory test data. In addition, abnormal values of certain parameters obtained from laboratory results are marked in red to serve as a warning. Miss Wang was taken to the recovery room post surgery. On her arrival in the recovery room, the reader located in that room detected her RFID wristband. Subsequently, the postoperative application displayed brief information about Miss Wang on the monitor, changed Miss Wang's status to -in recovery,? and recorded the arrival time in the database (See Fig.  {\ref 16}).\par
After Miss Wang recovered from anesthesia in the recovery room, the transporter brought Miss Wang from the recovery room to her ward. Because Miss Wang had leaved the recovery room, the readers were unable to receive the signal from the patient's tag. Therefore, Miss Wang's information was no longer displayed on the monitor and her status was updated to -ret urn to ward.? In addition, the screen located in the waiting area also updated the patient's status information to -return to ward.? 
\section[{Fig.16. User interface displayed in recovery area}]{Fig.16. User interface displayed in recovery area}\par
Scenario 2: Accidental Situations-As mentioned in chapter3, not every OR member completely follows the SOPs in real situations. Therefore, of some accidental situations happen, wrong-patient, wrong-site/side surgery, unsuitable anesthesia or wrong-OR event may occur. The following scenarios show probable situations that may threaten patient's safety in the as-is model.\par
Wrong OR Event-Based on the abovementioned scenario (Scenario 1), another patient who was assigned to OR-1 was mistakenly brought to OR-5 by a careless circulating nurse before Ms. Wang was brought to the room. Wrong Side Surgery Event-Based on the abovementioned scenario (Scenario 1), Ms. Wang's attending physician unexpectedly cannot perform the operation due to some reason. Another doctor, Dr. Chen, replaced her attending physician; this doctor was not familiar with the patient's condition. Furthermore, he memorized the wrong side of the operation site and did not check the patient's report.\par
Wrong Patient Event-Another patient, a woman with a similar name (Shiau-chin Wang, a pseudonym) was also admitted to the obstetrics and gynecology department; however, her operation was planned for the next day. The holding area nurse telephoned the obstetrics and gynecology floor, identified herself by name, and asked for -patient Shiau-chin Wang? (giving no other identifying information).\par
The nurse on the other end listened to the information, but did not reconfirm; the nurse mistook -S hiau-ching Wang? for -Shia u-chin Wang? informed the actual patient (Shiauchin Wang) that she would have to undergo an operation that same day and prepared her reports. The patient, although feeling slightly confused, assumed that the operation was advanced by one day. After a while, the transporter arrived at the obstetrics and gynecology department and asked for -patient Ms. Wang? (giving no other identifying information). Consequently, the wrong patient was brought to the OR suite. 
\section[{Demonstration of System Usage Scenario 2}]{Demonstration of System Usage Scenario 2}\par
Wrong OR Event-While the wrong patient was brought to OR-5, the reader located in OR-5 detected the patient's identity and checked it with the OR schedule. Since the patient was not assigned to OR-5, the system displayed a warning message bringing this fact to the nurse's attention (See Fig. \hyperref[fig_1]{17}). 
\section[{Fig.17. Warning message}]{Fig.17. Warning message}\par
Wrong-Site Surgery Event-Situations in which one doctor scheduled to perform an operation is substituted by another occur commonly in hospitals. However, whether a doctor is an attending physician or not, it is possible that he/she might memorize the wrong operation site; this is particularly true of substitute doctors who do not know the patient well.\par
Based on the scenario of wrong-site surgery, the system will automatically display the Ms. Wang's information including a chart on which the surgery site was marked while she was brought to OR-5 (See Fig.  {\ref 14}). Therefore, the doctor was encouraged to review the displayed information and did not have to look for the paper-based chart.\par
Wrong-Patient Event-In the abovementioned situation, the patient -S hiau-ching Wang? probably underwent a wrong operation. However, with the RFID-based OR system, the nurse could be forced to reconfirm by using the admission application system. When the nurse assigned the RFID wristband to the wrong patient -Shia u-chin Wang,? the system asked for the patient's ID card number. After the system compared the patient's ID card number with the OR schedule, a warning message would displayed (See Fig. \hyperref[fig_3]{18}). 
\section[{Fig.18 Warning message II}]{Fig.18 Warning message II}\par
If the nurse incorrectly entered the ID card number of the correct patient -Shia u-ching Wang,? the system would display the correct patient's information including the patient's picture (See Fig. \hyperref[fig_6]{19}). On seeing this displayed picture, the nurse would realize that a mismatch exists in the results and would therefore take corrective action.   {\ref 3}) actively provides patients' information to ensure that patients get correct procedures. The proposed system decreases the probability of medical errors such as wrong patients, wrong locations, wrong medical staff and wrong procedures. From the medical staff point of views, the system replaces some time-wasted manual input processes. Therefore, it will improve operational efficiency in the OR and consequently help medical professionals better manage patient care.\begin{figure}[htbp]
\noindent\textbf{123456}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Fig. 1 .Fig. 2 .Fig. 3 .Fig. 4 .Fig. 5 .Fig. 6 .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Fig. 7 .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{55}\includegraphics[]{image-4.png}
\caption{\label{fig_2}? 5 5 ?}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8}\includegraphics[]{image-5.png}
\caption{\label{fig_3}Fig. 8 .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{910}\includegraphics[]{image-6.png}
\caption{\label{fig_4}Fig. 9 .Fig. 10 .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{15}\includegraphics[]{image-7.png}
\caption{\label{fig_5}Fig. 15 .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{19}\includegraphics[]{image-8.png}
\caption{\label{fig_6}Fig. 19}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Failure to correctly identify patients constitutes one of the\\
most serious risks to patient safety; however, in the OR, it\\
can even cost a life.\\
Entering the wrong OR-In general, a teaching medical\\
center has numbers of contiguous ORs, each performing two\\
to three cases daily. Moreover, OR schedule varies\\
frequently. Hence, there are many opportunities for surgeons\\
or patients to enter the wrong ORs. If a patient or a surgeon\\
enters a wrong OR without reconfirm, the event of wrong\\
surgery could happen.\end{longtable} \par
  {\small\itshape [Note: Misidentification Of Patients-]} 
\caption{\label{tab_0}}\end{figure}
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