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DACCPM Team Creates Innovative Drug-syringe Label Printer

Codonics labelmakerA DACCPM team has developed a new drug-syringe label printer aimed at improving patient safety, eliminating medication errors and ensuring full compliance with all national labeling standards.

Currently in use in six ORs, the machine combines several aspects of labelmaking into one convenient system.

According to Dr. Ken Davison, the project started at a department meeting three years ago.

"Someone brought in an Omnicell machine as a pharmaceutical inventory management system that tracks who signs out medications and how much they sign out, and I said, 'Why can't we do this in the OR?", he said.

"Labeling syringes and vials started as a compliance requirement when the Joint Commission visited, and became a patient safety issue. It's part of our responsibility to put complete and correct drug information on every single syringe we prepare," Dr. Wilton Levine said.

The drug-syringe label printer contains four components: A touch-screen computer, printer, bar-code scanner and speakers. It can function with or without a network connection.

To create a label, clinicians simply scan their I.D. badges to log in, then scan the medication vial. A color label prints with the correct name of the drug, concentration, date/time of preparation, expiration date, and the preparer's initials.

The speakers provide audio feedback of the drug name to help eliminate drug swaps at the time of preparation. The speakers also read warnings, such as "warning, drug recalled" or "warning, syringe expired," aloud to the preparer, according to engineer Bill Driscoll, who worked with the Mass General Biomedical Engineering Model Shop to create the prototype.

In addition, the device can produce stickers to mark invasive lines, such as arterial lines, central venous pressure lines, and pulmonary artery lines, in addition to IV lines, Driscoll said.

The new labels meet the Joint Commission requirements and ASA guidelines. The streamlined operation takes less time and creates more accurate labels than the previous process, in which OR staff had to peel off each individual sticker they wanted to apply to the syringe and add all additional elements with a pen.

"Previously, only about 20% of the time all the information got onto a label. It was tedious and time-consuming," Dr. Levine said.

Because the accuracy has increased, "it's enabled us to run a set of safety checks we could never do before," he said.

To test the drug-syringe label printer's effects, the team designed two studies: A time-motion study to determine whether the new method was faster than the old method, and a study to evaluating labeling compliance. The studies found an improvement in the time it took to print new labels, accuracy of the new labels, and an increase in compliance from 70% to 100%.

The team members include Dr. Ken Davison, Mike Dempsey, Bill Driscoll, Gail Fishman, Dr. Wilton Levine, Dr. Nat Sims, Steve Spring, Kyle Vernest, and Kim Donovan. Dr. Karen Nanji designed one of the studies.

Team members noted that the patient safety project was both fun and incredibly rewarding.

"It's been the best project of my career," Fishman said. "The DACCPM is lucky to have resources to allow members to imagine, create, develop and implement such innovative safety projects."

The team has been recognized nationally with two awards at the 2008 ASA Annual Meeting: The Ellison C. Pierce APSF Award for Best Exhibit in Patient Safety and second prize for ASA's Best Overall Exhibit.

The technology has been licensed to Codonics, Inc., a medical device manufacturer in Cleveland, Ohio. Codonics plans to have commercially available units available by May 2010.

The project was funded by the Sims Innovation Lab and the DACCPM.

Pictured: The Codonics Smart Label System. Photo provided courtesy of Codonics.

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Department of Anesthesia,
Critical Care and Pain Medicine
Gray-Bigelow 444
55 Fruit Street
Boston, MA 02114

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