Beyond Color-Coding

Pucks replace traditional labels in the DISS. They act as a key that is secured in a tray lock, helping to prevent accidentally incorrect dosages by hospital professionals.

A developer has turned his attention to hospital medication errors and has created a multi-faceted system to fight them. Drug Index Safety Systems (DISS) comprises several steps and security levels designed to reduce errors in drug dispensation.

In addition, the system offers a way to tag product for item-level serialization on small packages short on label space. DISS creator Brent Dallman believes this will save lives, solve e-pedigree issues, and offer a unique business opportunity. His patent for the technology is for sale.

“I have several other projects I’d like to pursue,” Dallman says. “However, I believe this project has such power to improve drug delivery and save lives that I’ve put other projects on hold.”

Interlocking System

Two key elements make up the system. The first targets the problem of hard-to-read labels. In mistakes made at hospital bedsides, an estimated 25% are because of packaging or related errors, according to Med-E.R.R.S. and the Institute for Safe Medication Practices. Typical strategies to combat this have grown less efficient.

“Color-coding is becoming problematic, as dozens of new drugs are added to many hospitals in a single year,” says Dallman. “Being able to differentiate drug and dose is increasingly important. There are 300 separate drugs and dosages in an average hospital and only 25 viable colors.”

Dallman points out that highly concentrated pharmaceuticals come in small, 1- to 5-ml vials, and needall drug information, including bar coding or RFID chips, to fit on “a surface often smaller than a stamp.”
“The result is letters and critical numbers that are smaller than those on a dime,” he adds. “That would be unacceptable in just about any high-risk environment under the sun.”

Next, the second essential piece of the system lies in forced-function technology. This means that medication is physically restrained until the point of opening, in several layers.

Developers of the DISS say you can efficiently assess the day, date, drug, and dose of medication in their system without ever having to touch it.

A plastic puck adheres to the package at all times. Especially applicable to small vials, the expanded surface allows for additional information on the medication and acts as a way to convey a visual cue to its use.

The pucks replace standard vial labels, and are designed to be automatically attached at the same point on the production line as traditional labels. A pharmaceutical or contract packaging firm would be responsible for the application, avoiding human interaction and error that could come if placed at a pharmacy.

The system incorporates administration space in its safety precautions. First, the drawer key is placed where the medicine is kept. The lock is a flat plastic square with three prongs near the center.

The drug docking station holds a tray of drug bottles fitted with DISS pucks. Each tray has a particular lock that it can fit onto. The drug docking station will only hold matching keyed drugs. This step is intended to minimize health administrators pulling the wrong drugs.

With both the docking station and the puck, expanded labeling provides additional room for critical information, such as drug warnings and serialization details. The larger letters help with quick reads.

“Full pedigree and item-level tracking even on the smallest of vials is a first for products of this size,” Dallman says. “Electronic patient record systems pull important data together to streamline care and provide the highest quality care. Being effective with that technology means being able to electronically include all medications a patient requires not just those that have an easily scanable bar code.”

Dallman came to the idea from a background as a patent developer. His wife and DISS co-developer, Tracy Dallman, MD, is an anesthesiologist who serves on a pharmacy and safety committee at a major Indianapolis hospital. She provided Dallman with some insight into how errors can occur and what steps in the process are the greatest candidates for intervention.

He hopes that the technology will garner interest, as a branding opportunity and a chance to help patients.

“I’m looking for someone to take these patents and run with this idea,” Dallman says.