Enhancing Patient Safety With a Unique Device Identification Tracking System

Pingtung Veterans General Hospital Nursing Department poster at AORN Global Surgical Conference & Expo

In the fast-paced, high-stakes world of surgical care, precision is nonnegotiable—especially when tracking surgical instruments. At the AORN Global Surgical Conference & Expo held from April 5 to 9, 2025, in Boston, Massachusetts, a poster presented by Pingtung Veterans General Hospital and Weiho University unveiled a groundbreaking solution: a Unique Device Identification (UDI) barcode tracking system designed to bring traceability, safety, and efficiency to the surgical environment.

A Tangled Web of Surgical Tools

Surgical instruments are critical to patient outcomes, yet hospitals routinely face challenges such as misidentification, mispacking, and misplacement. These issues can delay surgeries, jeopardize patient safety, and make it nearly impossible to trace infections when only generic pack codes are available. Without pinpointing which instruments were used on which patient, infection control and root cause analysis are severely hampered. Recognizing this risk, the team sought to create a traceable, transparent, and technologically supported solution.

Innovation in Action

Launched on November 18, 2022, the hospital’s system assigns a laser-engraved QR code—just 2mm by 2mm in size—to every surgical instrument. Each code links to a database containing detailed metadata: the instrument’s name in both Chinese and English, model, dimensions, images, videos, country of origin, health ministry permits, and user manuals. This creates a living, evolving inventory system accessible to 655 hospital staff members for training, identification, and self-education.

During tray assembly, staff scan the QR codes to confirm instrument placement. If an item is misplaced, the system flags the error and displays the correct tray. This feature virtually eliminates packing errors. Additionally, sterilization and culture test results for each tray batch are scanned and logged into the system, ensuring only sterilized equipment reaches the operating room. Post-surgery, the tray barcode is linked with the patient’s medical record number, creating a comprehensive traceability chain.

Results That Speak for Themselves

Over the study period—November 2022 through June 2024—the system cataloged 14,453 surgical instruments. In that time, 179,620 trays were assembled with zero packing errors. Staff reported a dramatic time savings, with the average time for equipping trays dropping from 600 seconds to 180 seconds. This efficiency not only speeds up operating room turnover but also reduces the training burden on new personnel.

Crucially, the traceability function has proven invaluable. The system successfully linked 580,922 instruments to individual patient medical records. This breakthrough in documentation and transparency equips infection preventionists with the power to rapidly investigate and respond to surgical site infections, significantly enhancing patient safety.

Beyond Safety—Building a Culture of Learning

In addition to operational gains, the system provides an interactive, image-rich platform for staff education. Instead of static training modules, staff can explore instruments in detail online—learning their names, usage, and specifications through visual references. This reduces reliance on in-person instruction and supports competency-based training.

A Blueprint for the Future

This UDI-based barcode system represents more than just a tracking tool—it’s a holistic infrastructure that integrates inventory management, education, infection control, and patient care. By embedding safety and accuracy into every step of the instrument lifecycle, Pingtung Veterans General Hospital has set a new standard in perioperative practice.

In a landscape where seconds matter and errors carry life-altering consequences, this technology offers peace of mind to patients and professionals alike. It’s not just about equipment. It’s about elevating care.