How can hospitals prevent medication errors? One company with Fort Worth roots has an idea

Safen’s tags can be used to label intravenous lines and indicate what drug is being used for a particular patient. The tags were invented by former Fort Worth doctor Dr. David Friedman and designed to prevent medication errors in hospitalized patients. MARK HUMPHRIES Safen

When Dr. David Friedman was a young doctor in South Africa, he didn’t know much.

But one thing he did know was what drugs his patients were receiving in the cardiac unit of the old Johannesburg General Hospital. Friedman said he didn’t have to worry about mixing up the intravenous lines that pumped medicine into patients. The drugs were mixed with vitamin tinctures, which gave each drug a subtle dye — green, blue or yellow — indicating what drug was being used.

“I distinctly remember feeling reassured and gratified that even though I didn’t know how to manage these patients, I knew what was running through their lines, because I could see the color of the medication,” Friedman said

It was this easy-to-understand, color-coded system that Friedman had in mind when, decades later, he was working as a doctor in Fort Worth and thinking about how hospitals and other health care providers could better label intravenous lines, the plastic tubes that carry medication or fluids directly into the bodies of hospitalized patients.

Today, Friedman and his wife, Elizabeth Friedman, have designed and developed a series of tags that can be used to label IV lines, an effort to prevent medication errors in health care facilities. The products came on the market in October.

Friedman, who previously oversaw the bone marrow transplant unit at Cook Children’s Medical Center in Fort Worth, said his years working in hospitals helped him realize how easy it was for anyone — be it a doctor, a nurse, or the patient themselves — to mix up the various IV lines that were attached to a hospitalized patient. Did that line carry insulin or an antibiotic? Did this patient need more pain killers or an anticoagulant?

IV lines are prevalent in health care settings, especially in hospitals, nursing homes, and home health care. They are usually used to bring medicine or fluids directly into a patient’s body. Because they go directly into a vein, they allow patients to get medicine quickly. Patients with more complex problems might have multiple IV lines attached to them at once.

There is no universal standard for how IV lines are labeled, if they’re labeled at all, said Renae Franz, Safen’s chief commercialization officer. Some hospitals use a permanent marker and tape, but this option also poses risks: Tape has proven to be a good home for germs, and thus can pose an infection risk for hospitalized patients, many of whom are already at higher risk for infections.

Without a standard, it can be easy for busy doctors and nurses to mix up which IV line is carrying which fluid. One estimate of IV line errors concluded that about half of all medicines administered in U.S. hospitals had some sort of error.

“The beauty of our system is that it uses very simple shapes, colors, icons, and haptics to delineate what’s behind it,” Franz said.

The Friedmans, who now live in San Antonio, began working in earnest on bringing the idea for better IV line labeling to market in 2015, when Elizabeth founded Safen Medical to develop her husband’s invention. Over the years, the company has tested multiple different designs and adapted them as they received feedback. Today, the tags are manufactured by SigmaPro in Fort Worth. Elizabeth and her colleagues are working to spread the word about their invention to hospitals and other health care facilities looking to prevent medication errors. Safen medical tags are currently only available in U.S. hospitals that are using them on a trial basis, but the Safen team has started the process of marketing them to hospitals for use in future years.

The Friedmans’ work is part of a growing movement among health care providers to address patient safety and the harm that is sometimes inadvertently done to patients while they receive medical care. One study estimated that medical errors, including incorrect medications, kill an estimated 250,000 Americans a year.

Original Article:

Tell Your Story

Did a medication error affect you or a loved one, or have you experienced IV line medication errors as a healthcare provider? We want to know your story.