still not out of the woods. What's to prevent me from accidentally
picking up the wrong syringe, and falling prey to what's known as
syringe swap?
So what can you do to protect patients from imperfect staff? Here
are a few ways to take the human element out of medication adminis-
tration in the OR:
1. Label making. One solution is to equip each OR with a machine
that automatically prints labels when the anesthesia provider scans
the barcodes on the ampoules. That's certainly a good option,
although it's not ideal for a few reasons. One is that you have to buy a
machine for each OR, and they aren't cheap. Another is that it still
doesn't prevent you from putting the wrong medication in your
syringe. All it does is put an accurate label on the syringe, which you
may or may not notice.
But most concerning is that its efficacy is dependent on the willing-
ness of providers to use the thing. There isn't a lot of research on this,
but a study in which anesthesiologists were encouraged to use a label-
printing machine found that only about 40% followed through and did
so. The researchers even tried upping the ante. They said every day
you use it we'll give you a free coffee card. That bumped usage up to
about 70%. Even with the enticement of a free caramel macchiato,
roughly a third of the providers in the study found the process too
cumbersome to fully embrace.
2. Color-coded labels. This is another safeguard that could help
ensure the right medication reaches the patient on the sterile field. We
know that all opioid labels are blue, all paralytic labels are reddish
orange and all anesthetic labels are yellow.
There are two potential ways color-coded safety labels are effective.
One is that the drugs are easier to recognize. That's fine. But the more
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