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J Patient Saf. 2019 May 8. doi: 10.1097/PTS.0000000000000608. [Epub ahead of print]

Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room.

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Department of Pathology, Anatomy, and Laboratory Medicine, School of Medicine.
Department of Biostatistics, School of Public Health.
School of Nursing, West Virginia University Hospitals, Morgantown, West Virginia.



In a typical operating room (OR), there are many individuals who present all dressed in similar attire, making it extremely difficult to distinguish a person's role in the OR. Misidentification of an individual in the OR can make effective communication difficult, which could adversely impact patient safety. Furthermore, an inability to identify graduate medical students or distinguish students from OR faculty may hinder student learning opportunities within the OR. The purpose of this study was to determine whether implementation of a role-based, colored head covering requirement would improve identification in the OR and ultimately patient safety.


Operating room faculty and graduate medical students completed a four-question survey to assess opinions on misidentification in the OR, 1 month before and 2 months after a role-based head covering requirement was instituted in the OR. We analyzed the data from a total of 28 preintervention responses.


Before intervention, students and OR faculty reported that it was difficult to distinguish students from OR faculty in the OR. After intervention, there was a significant decrease in the proportion of respondents who felt that it was difficult to distinguish students in training from trained OR personnel from 79% to 42% (P = 0.007) CONCLUSIONS: Implementation of a role-based head covering system in the OR significantly increased the ability to determine a person's role in the OR. This study provides evocative support for a simple, inexpensive solution able to improve patient safety and learning opportunities for graduate medical students.

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