New seals on vials aim to promote medication safety

October 25, 2004

In 2004, one of the National Patient Safety Goals released by the Joint Commission on Accreditation of Healthcare Organizations focused on improving safety when using high-alert medications, such as paralytic agents.

In 2004, one of the National Patient Safety Goals released by the Joint Commission on Accreditation of Healthcare Organizations focused on improving safety when using high-alert medications, such as paralytic agents.

In addition, the recently released 2005 JCAHO National Patient Safety Goals include a new mandate to improve safety when using so-called look-alike, sound-alike drugs. Fortunately, for hospitals, a new product known as ShrinkSafe ID Bands promotes the safe administration of these agents and facilitates compliance with JCAHO safety goals.

ShrinkSafe ID Bands are plastic, shrinkable sleeves that slide over 10-ml vials containing paralytic agents, explained Mark Thrasher, product manager for Baxa, a U.S. distributor of ShrinkSafe ID Bands. With the application of heat from a heat gun or heat tunnel, the sleeve will adhere to the contours of the vial, added Robert Braverman, director of marketing for Medi-Dose/ EPS, the other U.S. distributor of the product.

The ShrinkSafe seal adds an additional layer of safe-ty to the use of paralytic agents, Thrasher said, because the clinician must peel away the seal in order to remove the vial's cap and access its contents. Essentially it adds a forcing function to the drug administration process, said Braverman, by requiring healthcare professionals to take an extra moment prior to administering the agent. "I call ShrinkSafe a, 'Hey, dude! Be careful!' product," he said.

Braverman and Thrasher explained that the initial point of sale for ShrinkSafe is the healthcare facility and that the product is applied at the hospital pharmacy level by either the pharmacist or pharmacy technician.

Pharmacists can raise awareness about safe medication practices at their institutions by using organizations such as JCAHO and the Institute for Safe Medication Practices ( http://www.ismp.org/) as resources, said Braverman. He also noted that most healthcare facilities have forums where the staff, including pharmacists, gathers to discuss issues such as medication safety.

"I think the key here is to use this product in conjunction with other strategies," said Michael Cohen, R.Ph., Sc.D., president of ISMP. "For example, rather than storing multiple neuromuscular products in vials, the pharmacy department and pharmacy and therapeutics committee should be working with the anesthesia, critical care, and emergency departments to restrict the variety of drugs in this class. In that way, you will have fewer individual drugs with different pharmacokinetic profiles and decrease the risk of any look-alike qualities bestowed by the 'Warning: Paralyzing Agent' overlay."

"Heightened awareness of medication errors in hospitals is the reason products like ShrinkSafe were developed," Braverman said. "Everyone in a facility should always be aware of the potential for medication errors. With the increased workload and activity in hospitals, it is easier than ever to rush through procedures. Our goal at Medi-Dose/EPS is to do everything within our power in terms of products and product design to minimize the potential for drug errors. Achieving that goal is of paramount importance to us, and this product fits hand-in-glove with our mission." He added that Medi-Dose/EPS hopes to develop bands in other colors for use with other classes of drugs.

Thrasher concurred. "At Baxa, we are always looking for ways to make our customers' processes more efficient," he said. "This product falls in line with our mission. When we heard about ShrinkSafe, we became very interested. The more we learned about the product, the more we realized that ShrinkSafe was fulfilling a timely need in terms of the reduction and prevention of medication safety errors."