How an Anesthesiologist Discovered a Simple Patient Safety Tool
By Christopher Walters, M.D.
During my 20 years as an anesthesiologist, I’ve appreciated the field of anesthesiology for being a leader in improving patient safety through technological innovation and training. Ten years ago, my own personal interest in patient safety innovation was heightened when I had the unfortunate experience of a patient medication administration error.
It Began with an Error in the OR
Anesthesiologists are constantly directly delivering medication straight to the patient through an intravenous line. There is no middle person involved, such as a pharmacist or primary care physician to write or administer a prescription. In the OR, things happen urgently and without warning, necessitating quick decision making and rapid medication administration under immense pressure. It was in this environment that I administered the wrong medication to a patient. I was devastated. After beating myself up, I realized that there was an opportunity to take action to help prevent this same mistake from happening to someone else.
Preventing Future Mistakes
If there had been a visual reminder at the IV tubing’s multiple injection ports (where the medication is delivered), my error would have been prevented. From this realization came the invention of Ident-Alert® IV Port Clips. They are simple, color-coded clips that attach to the injection ports along the intravenous tubing. The clips were developed to act as a “hard stop” visual reminder, warning that a patient has a medication allergy. They jar an anesthetist from their routine before the point of no return, the injection port. Though the clips began as a medication allergy warning on IV ports, I quickly realized the need for them as a visual cue throughout the hospital.
A Perfect Storm for Medication Errors
The strain on healthcare staff is at an all-time high. Pre-pandemic nursing workloads were already at a tipping point due to the increasing number of patients under the care of the typical floor nursing staff. Then came COVID-19. Nurses were called upon to go beyond job requirements, working extra shifts while facing dangerous exposure to an unknown, deadly virus. It was, and continues to be, the perfect storm in creating nursing fatigue and burnout. Hospitals are short staffed and the pressure to safely provide care is immense.
With this constant strain on medical staff has come an increased risk of medication administration errors and a need to improve workflow organization. I was fortunate enough to find PDC, a company that is already a leader in healthcare identification and safety products. They saw the symbiotic potential of partnering with me to develop and bring to market this much needed safety solution. Their willingness to partner with an individual clinician was a break from the traditional healthcare product development process. Together we have expanded the purpose of the Ident-Alert® Port Clips to be a hospital-wide alert and organizational tool. The clips come in universal medical alert colors and will fit on all standard intravenous tubing and injection ports.
A Critical Need in the ICU
In the ICU setting, a critically ill patient often has numerous intravenous lines with multiple life saving medications infused simultaneously. The nurse must keep track of the various medications and IV lines, often on multiple patients. Due to the complex and confusing twists and turns, these IV lines are often described as “spaghetti.” Implementing color-coded Ident-Alert® Port Clips on the lines can improve organization and patient safety. A designated colored clip will attach to the ports along a particular IV tube to represent a specific medication. The name of each medication can also be written on each clip for additional visual recognition.
Tapping into the Minds of Clinicians for Patient Safety
From the operating rooms to the ICU and hospital wings, it is becoming more evident that medical centers are under more strain than ever before. This has exposed a need for improved universal safety checks and innovative products to help balance the increasing need for exceptional healthcare with the declining number of healthcare professionals. While technology continues to revolutionize healthcare, the providers of patient care are still human. Medical errors continue to take place at alarming levels.
As clinicians, we see medical errors firsthand. It is my hope that more clinicians will bring forward their ideas to willing manufacturers. These unique partnerships and solutions will help prevent these costly medical errors. Tapping into this large pool of inventors with unique and innovative ideas, as PDC has done, will make hospitals a safer place for patients.
Dr. Walters is a practicing anesthesiologist in the Boston area. He has 20 years of experience and a passion for innovation that improves patient safety.