Scan4Safety in theatres brings together all of the Scan4Safety four Ps – Patient, Product, Place, and Process – in a single clinical setting.

By scanning a patient’s DCB1077 compliant wristband, the products used, the location, and staff involved, trusts can ensure accurate documentation, improve patient safety, and meet national reporting requirements. Through the use of GS1 data standards, Scan4Safety builds an information infrastructure with the potential to deliver significant value to patients, clinicians and the NHS.

Scanning products in theatres before their use can also help to reduce patient safety risks by alerting staff to issues such as expired products, product recalls, safety alerts and the selection of wrong products, for example, a left knee implant selected when the procedure is for a right knee.

Why does it matter?

Operating theatres are complex, high-risk environments where errors in patient identification, product selection, or documentation can have serious consequences. Traditional paper-based recording or manual data entry is time-consuming, and prone to error.

Several national inquiries have highlighted patient safety incidents, including metal-on-metal hip implants, breast implants, and vaginal mesh, and called for better tracking of medical devices from manufacturer to patient. When safety concerns arise, trusts using paper-based systems can struggle to identify affected patients quickly, delaying recall responses and potentially putting patients at risk.

Key benefits

Enhanced patient safety

Scanning at the point of care provides real-time alerts to theatre staff, helping to prevent errors before they reach the patient. Scanning products before use rather than after, ensures staff are alerted to safety concerns at the point of decision-making, not retrospectively.

Scanning a barcode at the point of care can flag:

• Products that have expired or are out of date
• Items subject to a product recall or field safety notice
• Laterality mismatches, such as a left knee implant selected when the procedure is for a right knee
• Compatibility issues between implantable components, which some systems can verify via the National Joint Registry
• Patient identification checks, confirming the right patient is undergoing the intended procedure

These automated checks provide an additional safety net, alongside manual verification, supporting surgical teams to deliver safer care.

Accurate, automated documentation

Scanning automates the capture of product data during procedures, replacing manual data entry and reducing the risk of transcription errors. This creates a comprehensive digital record linking each patient to the exact products used in their care, including batch numbers, expiry dates, and implant details. It creates a full digital record of every surgical procedure, by also capturing data on the staff involved and location.

Faster recall response

When a product recall or field safety notice is issued, trusts can identify affected stock locations within minutes rather than days so they can be removed. Vitally, the digital record enables near instant identification of which patients received a specific recalled product, allowing timely patient contact and clinical review.

Supporting the Medical Device Outcomes Registry (MDOR)

Scan4Safety in theatres directly supports trusts in meeting their requirements to submit data to the national Medical Device Outcomes Registry. MDOR was established following the Independent Medicines and Medical Devices Safety Review (the Cumberlege Report), which recommended a UK-wide database to record high-risk medical device procedures and link them to patient outcomes.

By capturing accurate data at the point of care, Scan4Safety enables trusts to:

• Submit timely, accurate data on high-risk device implantations
• Support national surveillance of device safety and performance
• Enable rapid identification of patients if device concerns arise
• Contribute to outcome analysis and quality improvement

Retained surgical items prevention

Retained surgical items such as sponges and instruments remain a persistent “Never Event” despite rigorous manual counting protocols. Barcoded sponge systems provide a technological check that is independent of the surgical team’s cognitive state, detecting significantly more counting discrepancies than traditional manual counts alone. Drawing on international randomised controlled trials, barcode systems identified substantially more discrepancies than standard protocols, offering an additional layer of protection in complex surgical environments.

Clinical time released

Automating documentation reduces the administrative burden on theatre staff, freeing up time for patient care. Staff spend less time on paperwork and manual stock checks, and more time focused on the procedure and the patient. One demonstrator site reported saving 15 minutes per case for clinical support workers, with more than 4,000 hours released back to direct patient care.

Financial and operational benefits

Accurate tracking of products used in theatre supports better stock management, reduces wastage from expired or unused items, and provides data to inform procurement decisions and automated reordering. Trusts gain visibility of product usage and costs at procedure level.

Example of how scanning in theatres works

Before the procedure:

• Patient identity confirmed by scanning their wristband barcode and verbal confirmation (where possible)
• Location and procedure details are recorded
• The system verifies the correct patient, site and planned intervention
• Staff involved in procedure recorded by scanning ID badges

During the procedure:

• Each product is scanned before use
• The system checks expiry dates, recall status and compatibility in real time
• Staff receive immediate alerts if any concerns are identified
• Implant details, including batch numbers and serial numbers, are automatically captured and recorded on electronic systems

After the procedure:

• A complete digital record links the patient to all products used, location and staff involved in the procedure, providing a comprehensive audit trail
• Data is available for national registry submissions
• Records support any future recall or safety investigations

Implementation

Implementing Scan4Safety in theatres typically involves:

• Ensuring all products at all packaging levels are barcoded to GS1 standards by suppliers
• Deploying scanning devices in theatre environments
• Integrating scanning systems with trust IT infrastructure, including electronic patient records and inventory systems
• Providing training and awareness sessions to theatre staff on scanning processes and responding to alerts
• Establishing governance and processes for acting on alerts and safety notifications

For many trusts, establishing an Inventory Management System provides a practical foundation for extending barcode scanning into theatres, building the infrastructure and processes needed for point of care scanning.

Links to other use cases

Scan4Safety in theatres connects with other applications across the trust:

• Inventory Management – ensuring stock is tracked from receipt to patient use
• Medicines Management – recording medications administered in theatre
• Blood tracking – recording of blood products administered in theatre
• Medical Device Tracking – supporting full traceability of implants and devices