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Can Labeling Reduce the Risk of Misconnections?

Nurse Buddy aims to clarify IV infusion line identification to eliminate mix-ups and misconnection, which may lead to medication error.

Patients receiving multiple, concurrent intravenous (IV) infusions often face a serious risk—the potential for misconnected tubing lines and dosing error. “Nurses check lines to make sure there are no mix-ups, unintended disconnections, or wrong doses. The consequences can be severe,” explained Elmer Vera, a registered nurse working in critical care for 18 years. “As the treatments for ailments become more advanced, the danger associated with multiple IV infusions continue to take lives right before the very eyes of the people who are responsible for their care, the nurses. Critically ill patients are particularly vulnerable because they receive multiple interventions with potent agents via numerous IV access routes. Errors are more frequent and fatal in neonatal and pediatric ICUs. Practices  are particularly  prone to errors, a glaring gap in the current standards.”

And no matter how careful nurses are, the risks still exist. “Your fingers can play tricks on you when you trace the line,” he added.

Vera told MD+DI that he noticed the challenges involved in ensuring proper connections when he began working as a nurse. So he decided he’d devise a better solution for “tracing the line.”

The risks had also hit home for Vera. His son had been diagnosed with Stage 4 Non-Hodgkin’s lymphoma in 2006 at age 13, he said. “Through the wonders of modern medicine, he is now cured, a nurse and about to become a father,” he stated. “I was very vigilant whenever nurses in pediatric oncology [would] hang his chemo drugs because as a critical care nurse I know medication error can happen anytime, anywhere. In 2011, I started toying with the idea, and the following year I published my work on nursebuddy.com.”

Soon the father and son started working together to improve Nursebuddy. As co-inventors in July 2017, they applied for a utility patent (USPTO) and formed Infusion Safety LLC, he said.

“I named the device ‘Nurse Buddy’ as a tribute to me and my son’s special relationship,” Vera said. “Nurse Buddy makes it easy for nurses to do the right thing.”

Vera took his design ideas to Steven Label, talking with Jon Pollock, Northern California territory manager. “I told Steven Label I wanted a ‘box’ label for tracing a line and an interlocking organizer label, all without any tape,” he said. And “to be MRI compatible, it also couldn’t have any metal.” Steven Label produced drawings for evaluation. “There were about six prototypes back and forth—Jon was very responsive and has the best team,” he added. “These are the people I want to work with to save lives by preventing medication error; they understand my vision.”

Of the final design consisting of color-differentiated line label markers, Vera said “the solution is foolproof. There is no mystery” about tracing the line. 

He explained that Nurse Buddy "is made of synthetic paper, a white matte plastic that is made from a mixture of polypropylene and polyethylene. It is writable, waterproof, tear-resistant and 100% recyclable."

The system is provided as a single piece that can be separated into two components, the box  and interlocking labels. "The box label can be assembled by folding the scored corners into a box held in place by folded locks and hangs on to the IV tubing under the infusion pump," he explained. "A 90-degree twist unlocks the box label and slides down the IV line. The interlocking label wraps around near the terminal end of the IV line. A matching drug name confirm the content of the IV tubing." For a demonstration of the box label assembly and interlocking label, view this link

Vera explained that "patients receiving multiple IV medications commonly have central lines with 1 to 3 lumens or access ports. The use of color is to distinguish one access port from another. This line differentiation enables the nurses to organize and identify the IV lines efficiently and group together medications to prevent drug incompatibility reaction. A high visibility masking tape  (0.5 inch wide) can be attached across the bottom half of the box label and its color should be consistent with the interlocking label." 

The labels are designed to be assembled in medication room or bed side, but the possibilities are endless. “This is my mission in life, not only at the bedside, but to spread the idea to other healthcare professionals,” he said.

Vera also told MD+DI that "in 2012, Sonia Pinkney, a human factors engineer at the Centre for Global eHealth Innovation, University Health Network in Toronto, Canada sent me an email inquiring about Nurse Buddy.  She is a part of the Health Technology Safety Research Team (HTSRT) conducting a multi-phase research study on mitigating risks associated with multiple IV infusions.  One phase of the study consists of a simulated laboratory study to identify and quantify the effectiveness of potential mitigating solutions (both technical and practice-related).  In researching potential interventions to manage IV line complexity, she came across  Nurse Buddy. 

"The study, involving 40 ICU nurses from a Toronto hospital, is the first empirical comparison of methods to reduce mix-ups with multiple IVs," he continued. "Eleven IV lines were used to simulate a typical case. The combination of labels and organizers improved both accuracy and efficiency in identifying IV lines. No errors occurred when using the Nurse Buddy line organizer and pre-printed labels. The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency." Infusion Safety shares a link to the study published in the Critical Care Medicine Journal in the July 2019 issue. 

"Based on these findings, we zeroed in on developing an enhanced, simple, and foolproof system to reduce if not eliminate medication errors and misconnection. Nurse Buddy is an integrated infusion system that decreases visual complexity, augments organization, and improves visual feedback to nurses."

Nurse Buddy is sold online for $3.00 each or $250 for a box of 100.

Nurse Buddy was displayed at Steven Label & Robinson Printing’s Booth at BIOMEDevice San Jose last December (where MD+DI got to see a demo; picture above) and will be at Steven Label & Robinson Printing’s Booth (#1854) at the upcoming MD&M West 2020 show in Anaheim, on February 12th from noon to 3pm.

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