LinkedIn Hard Cases|How a Mother’s Grief Led to an Invention to Improve Patient Safety
This article is part of LinkedIn’s Hard Cases series, where doctors and medical professionals share the toughest challenges they’ve faced in their careers. You can read more about it here and follow along using hashtag #HardCases.
By Jean Snyder, Owner, Jean F. Snyder CRNA Inc., Co-owner Goodwin and Snyder Anesthesia Associates, PLLC
I can still remember it like yesterday. It was the day I read a mother’s story of her son dying because of a mistake during surgery. The sun was streaming through the window into the corner of my family room where my computer sat, and I was sobbing when my husband walked in the room and asked what was wrong. I could barely choke out the words: this poor mom lost her son because of an anesthesia mistake. I still feel the tears rising in my eyes as I tell this story not only because of this motherly bond that cannot comprehend the loss of a child but because I am a nurse anesthesiologist. I understood the story from both sides and this mother’s story was a heavy weight on my heart. It still is. It is the reason I invented ERMA and it is what gives me the passion day after day to pursue the hardest job I have ever taken on – developing and selling a product that I know will improve the safety of anesthesia every day and for every patient.
In 2008, The Joint Commission released National Patient Safety Goal 03.04.01 that addressed the labeling of medications. Included in this element of performance was the mandate to save all vials and syringes until the completion of a procedure. As an anesthesia provider, I noticed the difficulty with compliance as anesthesia providers had no safe mechanism to sequester these items. Soon afterwards, this portion of the mandate was redacted but I knew that safety critical areas like anesthesia need that exact mechanism. It was obvious that there was value in the retention of syringes and vials in the course of an anesthetic.
I developed the ERMA (Error Reduction and Mitigation Aide) prototype in 2008 but had no means to refine and market it. In 2016, as part of my nurse anesthesia doctoral program at Virginia Commonwealth University, I wrote a whitepaper about medication errors within the context of error critical systems. ERMA is a means to allow early recognition and, hopefully, mitigation of medication errors. I then submitted my whitepaper and prototype to The Innovation Institute, a medical device incubator that is affiliated with my hospital system. The Innovation Institute worked with me to refine ERMA and obtained a patent. We are presently conducting research and working to market ERMA.
ERMA is a clear reservoir inserted between the re-entry proof top and opaque terminal disposal portion of a traditional needle box. It allows practitioners in every high-risk area (OR, ED, ICU) to visualize all syringes and vials used during the course of a procedure, anesthetic or surgery. At the end of each procedure and after confirming the correct and complete medication record with ERMA, a trap door in the bottom of the reservoir is released to allow the used vials and syringes to drop into the bottom of the needle box for terminal disposal. In the event of an unexpected and untoward event, providers have visual proof that what they believed they had administered is actually what they administered. If an error was made, ERMA allows us to recognize errors in a timely fashion and address the untoward events. If you are a provider, you will understand that the value of ERMA is simply, “What would you give for a second chance?”
Research has revealed that medication errors occur despite concentrated efforts to prevent them in part because medication administration has become increasingly complex. In addition, providers are distracted, tired, face environmental barriers such as low lighting as well as production pressures. In anesthesia, the normal system of checks and balances in the administration of medication is eliminated as one person prescribes, prepares, administers, and charts the medication. A single anesthetic often administers several doses of up to 20 medications. Dr. Karen Nanji et al determined that 1 in 20 perioperative medication administrations and every second operation resulted in a medication error and/or an adverse drug event. ERMA allows medical personnel that crucial second look or a process that makes sure that the medication they thought they were giving is actually the medication they gave. If an error was made, it buys the practitioner precious time is often wasted in trying to figure out the precipitating cause of a medical crisis.
All health care workers function in a complex, high pressure environment. We are also humans and make errors. ERMA gives health care workers one more tool to provide excellent care. ERMA provides redundancy in an error critical system which makes medication delivery safer and reduces medication errors. It also allows providers the ability to recognize an error earlier and in a best-case scenario, mitigate said errors.
We are facing the marketing challenge now because it is hard to make change in medicine and it is hard for practitioners to admit we make mistakes. The widespread adoption of ERMA would require hospital systems to place patient safety foremost and make the ethical choice to replace standard needle disposal boxes with ERMA, thereby placing safety before profit. I would be extremely gratified to hear practitioners in high risk areas tell me that ERMA helped them recognize and mitigate a medication error. My biggest reward would be to meet Dale Ann Micalizzi, Justin’s mother, to tell her that her loss and Justin’s death, were not in vain. I want to let her know that her story motivated me to change the way we recognize medication errors and that my product may prevent another family from suffering such a great loss. #Justinhope
I believe all nurses are inventors at heart. We innovate every day. We develop workarounds every day. We don’t have the power and means to move our ideas to reality alone. Despite the challenges, ERMA has been an amazing personal journey. ERMA led me to pursue my doctorate in nurse anesthesia at VCU. I have learned that I have the heart and mind of an inventor. I hope my story encourages other nurses to innovate, to seek improvements in the name of patient safety and to find the silver lining so that the loss of a patient from a medication error is not a life lost in vain. More…