Our systems should be built for the “ pilot” having their worse day and their best day. There are several systems solutions to this error but unfortunately many centers haven’t implemented them. The mantra in medicine is try harder read the label etc those things are important but given the inherent cognitive imperfections of the human brain will never be reliable solutions. Thanks for sharing Ron
Great points John - there are engineering solutions but will take dedication to the cause. They will be covered in future editions of PAAD. I think the ASA really messed up when they adopted the lighthouse and the motto "Vigilance" back in the 90s. Vigilance doesn't work, it never will.
Good case discussion, at first I was concerned about identifying the patient, but I see that with Mom's advocacy, I'm sure you have her blessing. Most institutions but not all have taken steps to avoid errors like the one you describe. Rearranging the drug layout is one. I am also a strong advocate for some automated bar-coding/drug labeling system in the OR. There are several on the market and it allows the organization to kill two birds, labeling requirements and decreasing drug swap risk, with one stone.
I would like to encourage you in your position with ISMP to encourage the pharmaceutical industry to decrease with look alike drugs and drug concentrations that have to be altered prior to use.
Many thanks Al for the good points. Epic's Anesthesia module now has built-in bar-coding functionality, as long the hospital pharmacy has pre-set up the drug libraries. Many places don't even know it exists, so if you're reading this, try "zapping" the 2D bar code on the vial or prefilled syringe to see what happens. I don't know about any other vendors. As far as ISMP and the pharm industry, that's a tall order because of drug shortages and the use of so many different generics out there now. I think the key is to assign a person in charge at each institution to be the OR med safety czar, and work on these issues - they will differ between institutions. Good to hear from you!
Ron this is my recurring nightmare. I actually envision this situation in my sleep and wake up in a cold sweat. I have seen and photographed too many look a like vials and I have been spooked. I like the comment about how vigilance is not enough or a reliable system. I want to know how do we force drug manufacturers to be a part of the solution. Why is there no standardization of how vials look. Drugs that need to be diluted should also have a different method in how they are drawn. In my mind that would be one place where we could start. My biggest question is how can I as a practitioner do more to change the system?
Lenny - thanks for the candid comments...the reason why vials are not standardized is complicated, and hasn't been taken up at any legal level. The best we can do right now is to bypass the vial and order as many pre-filled, pre-labeled syringes as possible. Not all are available (eg propofol for obvious reasons) and there is the issue of increased cost, but if we eliminate vials, then vial swap is impossible. Many centers have invested in the Codonics system, but I don't believe that's a good solution, because it still encourages the use of vials, and the money spent will be shunted away from buying prefilled syringes.
Ron, thank you for another great discussion. What a horrible case to read about. I couldn't agree more that solutions need to involve correcting the system and not just education and telling providers just to pay more attention. After many years of working in a patient safety role, I also want to stress the importance of calling risk management/ patient safety early. I have often times seen an inherent distrust or skepticism when these teams get involved. They are there to help and not blame! Even adjusting or forgiving a medical bill when an error was committed goes a long way. The bill that comes after an event can just add fuel to the fire.
This is an anesthesiologist’s worst nightmare, we all want to take good care of our patients and try our best but as soon as we hear ASA1 we let our guard down, and the similar top vials are not helping either.
I have posted numerous pictures of the “anesthesia blues and oranges” on Twitter there has to be a change.
Besides that the Pyxis continue to have ondansetron and phenylephrine vials stocked next to each other.
Patient safety is not the sole responsibility of anesthesia professionals.
That's a great point about letting our guard down with an ASA 1 patient. Phenylephrine vials, the concentrated ones that are used to make infusions, should be completely separated from all other meds. Ideally, it should be provided in a prefilled, prelabeled syringe. Recently, while inspecting a hospital's perioperative med safety program on behalf of ISMP, an anesthesiologist told me that because they are getting so many look-alike vials from different generic manufacturers, it's forcing them to read the label more carefully!
Our systems should be built for the “ pilot” having their worse day and their best day. There are several systems solutions to this error but unfortunately many centers haven’t implemented them. The mantra in medicine is try harder read the label etc those things are important but given the inherent cognitive imperfections of the human brain will never be reliable solutions. Thanks for sharing Ron
Great points John - there are engineering solutions but will take dedication to the cause. They will be covered in future editions of PAAD. I think the ASA really messed up when they adopted the lighthouse and the motto "Vigilance" back in the 90s. Vigilance doesn't work, it never will.
Ron,
Good case discussion, at first I was concerned about identifying the patient, but I see that with Mom's advocacy, I'm sure you have her blessing. Most institutions but not all have taken steps to avoid errors like the one you describe. Rearranging the drug layout is one. I am also a strong advocate for some automated bar-coding/drug labeling system in the OR. There are several on the market and it allows the organization to kill two birds, labeling requirements and decreasing drug swap risk, with one stone.
I would like to encourage you in your position with ISMP to encourage the pharmaceutical industry to decrease with look alike drugs and drug concentrations that have to be altered prior to use.
Al
Many thanks Al for the good points. Epic's Anesthesia module now has built-in bar-coding functionality, as long the hospital pharmacy has pre-set up the drug libraries. Many places don't even know it exists, so if you're reading this, try "zapping" the 2D bar code on the vial or prefilled syringe to see what happens. I don't know about any other vendors. As far as ISMP and the pharm industry, that's a tall order because of drug shortages and the use of so many different generics out there now. I think the key is to assign a person in charge at each institution to be the OR med safety czar, and work on these issues - they will differ between institutions. Good to hear from you!
Ron this is my recurring nightmare. I actually envision this situation in my sleep and wake up in a cold sweat. I have seen and photographed too many look a like vials and I have been spooked. I like the comment about how vigilance is not enough or a reliable system. I want to know how do we force drug manufacturers to be a part of the solution. Why is there no standardization of how vials look. Drugs that need to be diluted should also have a different method in how they are drawn. In my mind that would be one place where we could start. My biggest question is how can I as a practitioner do more to change the system?
Lenny - thanks for the candid comments...the reason why vials are not standardized is complicated, and hasn't been taken up at any legal level. The best we can do right now is to bypass the vial and order as many pre-filled, pre-labeled syringes as possible. Not all are available (eg propofol for obvious reasons) and there is the issue of increased cost, but if we eliminate vials, then vial swap is impossible. Many centers have invested in the Codonics system, but I don't believe that's a good solution, because it still encourages the use of vials, and the money spent will be shunted away from buying prefilled syringes.
Ron, thank you for another great discussion. What a horrible case to read about. I couldn't agree more that solutions need to involve correcting the system and not just education and telling providers just to pay more attention. After many years of working in a patient safety role, I also want to stress the importance of calling risk management/ patient safety early. I have often times seen an inherent distrust or skepticism when these teams get involved. They are there to help and not blame! Even adjusting or forgiving a medical bill when an error was committed goes a long way. The bill that comes after an event can just add fuel to the fire.
Thank you Laura - excellent points!
This is an anesthesiologist’s worst nightmare, we all want to take good care of our patients and try our best but as soon as we hear ASA1 we let our guard down, and the similar top vials are not helping either.
I have posted numerous pictures of the “anesthesia blues and oranges” on Twitter there has to be a change.
Besides that the Pyxis continue to have ondansetron and phenylephrine vials stocked next to each other.
Patient safety is not the sole responsibility of anesthesia professionals.
That's a great point about letting our guard down with an ASA 1 patient. Phenylephrine vials, the concentrated ones that are used to make infusions, should be completely separated from all other meds. Ideally, it should be provided in a prefilled, prelabeled syringe. Recently, while inspecting a hospital's perioperative med safety program on behalf of ISMP, an anesthesiologist told me that because they are getting so many look-alike vials from different generic manufacturers, it's forcing them to read the label more carefully!