Sunday, June 20, 2010

Color coding and safety...

The Feb 4th, 2008 blog entry, prompted by the lawsuit that the Quaids had filed against heparin-maker Baxter following the Cedars-Sinai medical error that gave their twins a serious overdose, disagreed with their contention that "... since a medical error in administration could lead to a dangerous or fatal result, the background colors should have been different... and... the vials should have been in completely distinguishable size and shape..." The entry argued that color-coding "... would contribute to the natural tendency of folks to use color and/or shape and size as a proxy or 'shortcut'. It could well be argued that making every label color uniform would improve patient safety, as providers would then be obliged to actually read the label and confirm the drug/dose rather than rely on color or some other visual cue.." and suggested that Quaid concentrate on other systems changes, such as bar-coding. Well, Quaid has joined up with others and is doing yeoman work spreading the word on preventing medical errors, see the Quaid Initiative for more information... However, he still seems to believe that color-coding would have helped, as evidenced by his re-filing of a lawsuit against Baxter in a different venue...

The subsequent Aug 18th, 2008 entry criticized Quaid for setting up his own foundation for attacking the problem of medication errors, rather than working with existing bodies... Well, in April 2010 the Quaid Foundation merged with The Texas Medical Institute of Technology (TMIT) - "... a medical research organization, founded in 1984, dedicated to accelerating performance solutions that save lives, save money, and build value in the communities we serve and ventures we undertake. Our core values drive our behaviors and in turn drive our culture. TMIT applies the Institute of Medicine's (IOM) design principles of patient-centeredness, evidence-based medicine, and systems performance improvement..."

A number of organizations are circulating an e-petition to the FDA on the subject of eliminating "look alike, sound alike drugs" While seeking the elimination of an existing color scheme (where different container and cap colors were aligned with different therapeutic classes e.g. green for miotics), their insistence that no two drugs/strengths look alike would of necessity lead to a complicated color scheme.

Is this a good idea? This blogger would think not. In fact the pictorial examples that they present (see above, more examples at the link) as prima facie examples of problems are exactly what this blogger would argue for i.e. identical label color schemes - so that providers have to read the labels to know the ingredient rather than relying on color-related short cuts.

This blog entry would seem to agree....

Previous related blog entries:
Color-coding is this a good idea? - Feb 4th, 2008
Founders - Aug 18th, 2008

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