A Context-aware Patient Safety System for the Operating Room

Jakob E. Bardram & Niels Nørskov

Patient Safety

• Institute of Medicine: “To err is Human”– 9% adverse events, 40% related to ‘errors’, 60% to

complications– Danish studies confirm this

• Utah and Colorado– Operative adverse events comprised 44.9% of all adverse

events

• Joint Commission (JCAHO protocol)– Universal Protocol for Preventing Wrong Site, Wrong

Procedure, Wrong Person Surgery (the 3Ws)

• Danish Recommendation– Improve communication and coordination– Improve patient identification– …

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Source: • Institute of Medicine• E J Thomas et al (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care., vol. 38, no. 3.

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A Context-aware Patient Safety System

• Context-awareness– RFID sensor input + other input– Based on the Java Context-Awareness Framework (JCAF)– Extended with reasoning engine (JESS)

• Features– Presenting relevant information during operation

• PACS, EPR, Operation data

– Monitors progress and fire warnings• Patient, Team, Blood, Patient Status, Equipment, …

• Clinical Proof-of-Concept– Full functioning prototype– Deployed inside one OR with a full surgical team– Used during one day (no real patients, however)– Qualitative evaluation

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Related Work

• Research on Context-aware Hospital Systems– AwareMedia & AwarePhone– Context-aware Communication (Video + Messaging)

• Systems inside the Operating Room (OR)– Context-Aware Peri-operative Information System– OR Dashboard– Automatically building the Electronic Medical Record (EMR)– Logging of events (including staff and patient entrance)

• Commercial Systems– GE Captus process monitoring system– SurgiChip – explicit support for the JCAHO protocol– Focus on specific context information, location or id of the

patient

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CAPSIS – A Context Aware Patient Safety and Information System

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Research Methods

• A user-centered design process (~10 clinicians)– observational studies– workshops w. surgeons, anesthesiologists, nurses,

operation technicians, and hospital managers– prototyping

• … combined w. litterature and adverse event studies

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FutureWorkshop

FutureWorkshop

PaperMock-ups

PaperMock-ups PrototypePrototype

Design Principles

1. Promptly identify safety hazards in the OR2. Meet best-practice standards of patient safety in

the OR (e.g. the JCAHO protocol)3. Should augment – rather than automate – current

patient safety procedures4. Both help in finding and displaying relevant

information during surgery, and issue warnings when a potentially dangerous situation is detected.

5. Sensing and reasoning accuracy should be high because of the safety-critical nature of the system

6. Should remain unobtrusive and require as little user feedback as possible.

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CAPSIS UI

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Context-Related Clinical Information

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CAPSIS Architecture

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Context Acquisition & Distribution

Context Management & Reasoning

Clinical Proof-of-Concept (aka “Evaluation”)

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Clinical Proof-of-Concept

• Full functioning prototype– Tracing patients, staff, blood, equipment

• Deployed inside one OR with a full surgical team– 11 participants,

• Used during one day– 8 operations– no real patients, however (2 staff members acting)

• Qualitative evaluation– Perceived usability and usefulness questionnaire– Note: No Evidence-based Medicine

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References: J. E. Bardram. Pervasive healthcare as a scientific discipline. Methods of Information in Medicine, 47(3):129–142, 2008.

F. D. Davis. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13(3):319–339, September 1989.

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Results

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Context-aware Information I

• “In relation to the EMR, it is beneficial that the system looks up the right parts of the medical record. This means that we do not need to spend so much time navigating round the data to find the current operation. [...] Some patients may have many concurrent treatments...”

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Context-aware Information II

• “[...] precisely the fact that you have the visual overview inside the OR – having both the patient’s images as well as the name and SSN number together with the paper-based [referral letter]. That I think improves patient safety.”

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Context-aware Safety

• “It will also improve safety [...] you know, when you’re in the middle of a [safety] procedure and you get disturbed by something. Then – who is supposed to be doing what? If you have looked at the screen and it has done the checking, you are much more confident [...] than if there are just people doing it manually.”

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Discussion

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Confidence in Context-Aware Systems

• Safety Critical systems– The consequence of an error, failure, or mistake may be

fatal

• Confidence– Accuracy in context acquisition– Accuracy is conserved “up the context stack” for later

access– Reasoning can be trusted and verified

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CAPSIS Architecture

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Accuracy is measured and

maintained

1st order logic reasoning

The Confidence-Consequence Matrix

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Summary

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Summary

• Introduced the use of context-aware technology to improve patient safety during surgery

• CAPSIS– Providing relevant and timely information during surgery– Issuing warnings if something seems to be going wrong

• Clinical Proof-of-Concept– 1 day, 11 clinicians, 8 surgeries– Perceived usefulness and usability– Clear indication for the benefit of the use of context-aware

technologies inside the OR– Next step: clinical evidence (i.e. randomized trials)

• UbiComp: Are we ready to face the tough cases?– Can our technology be used for safety critical systems?

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Questions?

Jakob E. Bardrambardram@itu.dkwww.itu.dk/~bardram

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In cooperation with