Medication labelling needs error-proofing NOW

Bureaucratic solutions too-little too late to save lives

Today I read an article in the NP that needs a lean response. Tom Blackwell's article puts light on a serious problem in health care: confusion over similar looking labels has led to mistakes causing death. The tragic deaths of 2 people in Calgary who while undergoing dialysis were given deadly potassium chloride instead of harmless sodium chloride solution; a mistake traced to the extreme similarity of the packaging and labelling. The article quotes pharmacy professor Neil MacKinnon: "If you ask any kind of front line nurse or pharmacist they would say 'Gee, this isn't rocket science, why can't they make labelling clearer- put things in different size fonts and colors?' It's a big problem we've known about for a long time but there doesn't seem like a lot of impetus for change." 

The government and industry are working on a standard bar code system for use with scanners - a highly expensive solution that will take "years" to implement. Health Canada is also being asked to vet labels and packaging that may lead to mistakes. They are committing $2 million to a system for REPORTING incidents and developing preventive measures! I am sure the reporting system will comfort the next family that loses a loved one.

This example screams for simple and immediate implementation of lean methods. It is not rocket science. Although the bureaucracy is doing its "best",  action on this problem need not be delayed.  Error proofing is a basic concept of lean. You simply devise ways to completely prevent common and likely errors. A lean manufacturer would immediately address this issue and market the improved safety. Luckily the Institute for Safe Medicine Practices in Atlanta has begun positive work with drug suppliers but it is clearly not moving as fast as is needed. Interestingly they have a system standard of TALLMAN letters for labels that emphasize the differences between similar medicines right on their label. Why is this not industry standard?

 Interested lean leaders would simply ask the front line workers to identify the most likely confused medications. Thereby creating an immediate database of improvements to tackle, heading off mistakes in the short term. I bet there are many simple (and cheap) error proofing ideas on the minds of health care workers waiting to be engaged.  Lean is about making improvements right now using the expertise of the front line workers.  It is ironic that the bureaucracy has such a hold on "improvement" that even simple changes that save lives can't be made quickly.  Isn't saving lives quickly is what health care is all about? I would start with those on the front line, not waste time installing long term costly "solutions" or developing a reporting system that costs more than the solutions to most of this issue would. It is sad that lean in health care at the national level in Canada is not visible at all.