Low-Tech Safety

The study, presented in October at the annual meeting of the American Society of Anesthesiologists, involved volunteer anesthesiologists, residents, and nurses drawing medications with different colored labels at a gradually increasing speed to simulate an emergency scenario. When the color of the syringe label matched the medication bottle's label, fewer near-mistakes occurred compared to when the colors didn't match, according to the study. Additionally, when peel-off labels were removed from the bottle and placed on the syringes, errors were reduced and fewer commands were skipped. "If you either match the colors or match the styles, it's harder to make a mistake," says Elizabeth H. Sinz, MD, who along with Donald E. Martin, MD, headed the Penn State Hershey research team.

The artificial circumstances of the study have raised some validity questions, but studying medication errors in actual practice presents significant ethical challenges, Sinz says. "You can't walk around and let people make errors." Further, people who are being watched are less likely to make errors, she adds.

Hurdles to clear
But if something so seemingly simple as standardizing medication label colors or using peel-off labels could yield significant error reductions, why hasn't the idea been embraced on a wider scale? For one, such labeling is more expensive, Sinz says. For another, the regulatory hurdles would be considerable. Perhaps most significant, however, is the pervading perception that such solutions hold less promise than RFID, for example. Sinz acknowledges that there is "probably a role" for some advanced technologies, and that certain innovations work well in certain patient settings. But she cautions that the patient safety community should recognize the limitations of technology.

"In addition to being expensive, these technologies are almost always excluded when it comes to emergency drug administration, they require a lot of extra work, and in an emergency situation, you can't get the drugs flowing fast enough," she says. "A lot of errors created by those methodologies—the label was wrong, or maybe the band was unreadable—tend to be dismissed as if they're not important, but if you're trading one set of errors for another, you haven't solved the problem."

For her part, Richards says Kaiser South San Francisco has turned to other low-tech solutions in addition to the vest program. An area of red vinyl on the floor around medication stations has helped to further define a physical area in which nurses should not be interrupted. The hospital also uses a product called a "Yacker Tracker," which has a basic traffic signal design and measures the noise in a given room; if the noise is in the proper decibel range, it shows a green light.

Like Sinz, Richards appreciates the value of technology, but adds that caregivers must "make sure we're still including the patient as we turn toward the computer that's right next to us." She recalls one incident when she was an ICU nurse in which a young patient was having repeated seizures before being examined by the ICU chief.

"He was livid with the residents and wanted to know who had seen this patient, because they had failed to actually touch this patient and see she was pregnant," Richards says. "Why are we forgetting to touch the patient? We have to remember to keep the focus on the patient."