Inventor Tim Kraushaar is no stranger to hospitals. His dad was a surgeon and Tim has designed some helpful devices for medication delivery. He was observing operations at a Southern California hospital a few years ago when a patient coded after being given medication through the wrong IV line.

"A loss of life was caused because a nurse inadvertently pushed contraindicated medication into the IV line. She pushed 25 cc of Demerol in the dopamine line. There's no recovery from that," Kraushaar reflects. He notes that this kind of error is not uncommon, although it does not always prove fatal. It is almost always underreported.

He decided to do something about the problem and invented ERrorSafe Identifiable Intravenous Systems. These unique and simple IV administration sets identify IV lines from top to bottom so clinicians can inject or infuse medication quickly, safely, and confidently.
Patients in ER, ICU, or cardiac care in particular often have multiple IV lines and sites for multiple drug delivery. It is absolutely vital that nurses understand which medications are being delivered into which sites since some medications become toxic when mixed directly together. The ERrorSafe system is designed to prevent the problem through simple color coding and numeric labeling.

"[The system] identifies each line by a color code and number and follows it down from the drip chamber to the Y-site [patient] so that it makes the nurse's job much easier and saves time because it is so easy to use," says Joni Poole, RN. "It's a quick visual connection between the medicine bag and the Y-site. Before that we used labels. You had to stop, fill out a label--and the labels look the same."

"When you have a patient in cardiac ICU where they are barely stable, you will see nurses putting tape on lines and bags to keep track of their lines. That's a foolish way to do things. I've seen labels fall off," Kraushaar says. "If you identify the medicine bag, drip chamber, and Y-site you don't have to trace lines down hand over hand."

Instead, the ERrorSafe system uses colors and numbers to quickly spot the open line. "For example, a nurse can just say, 'the open line is red number 3,' and they immediately know where to push the medication," he says.

The system also helps in administering isotopes and encourages clinician safety. "On numerous occasions you hear about technicians who stuck themselves or dripped isotope on the floor by going through the line," observes John Zacharczuk, CEO, American Allied Imaging Inc., Brea, CA. The company specializes in nuclear medicine. (Picture a stress test in which a patient is running on a treadmill during the injection.) The ERrorSafe system is designed to prevent these problems by using an ergonomic shape to keep hands clear of the injection port. "When you grab it, intuitively, you can only grab it one way so that technicians hold it accurately and it diverts the needle away from the fingers."

The ERrorSafe system works with drip bags or infusion pumps and includes connectors compatible with major brands of pumps.

"I could not interest the major [infusion pump] companies to pursue the product as an addition to their IV lines, so I built a kit that would retrofit each line," Kraushaar explains. The kits retrofit Baxter, Abbott, Alaris/Cardinal, and other manufacturers' IV systems that work with their infusion pumps.

ERrorSafe Identifiable Intravenous Systems are distributed by Summit Medical Technologies. For information go to: http://www.summitmedtech.com/errorsafe.php

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