J Korean Med Sci.  2017 Dec;32(12):1938-1946. 10.3346/jkms.2017.32.12.1938.

Adapter-based Safety Injection System for Prevention of Wrong Route and Wrong Patient Medication Errors

• Cho YC
• Lee SH
• Cho YH
• Choy YB

• KMID: 2396369
• DOI: http://doi.org/10.3346/jkms.2017.32.12.1938

Abstract

Wrong-route or -patient medication errors due to human mistakes have been considered difficult to resolve in clinical settings. In this study, we suggest a safety injection system that can help to prevent an injection when a mismatch exists between the drug and route or patient. For this, we prepared two distinct adapters with key and keyhole patterns specifically assigned to a pair of drug and route or patient. When connected to a syringe tip and its counterpart, a catheter injection-port, respectively, the adapters allowed for a seamless connection only with their matching patterns. In this study, each of the adapters possessed a specific key and keyhole pattern at one end and the other end was shaped to be a universal fit for syringe tips or catheter injection-ports in clinical use. With the scheme proposed herein, we could generate 27,000 patterns, depending on the location and shape of the key tooth in the adapters. With a rapid prototyping technique, multiple distinct pairs of adapters could be prepared in a relatively short period of time and thus, we envision that a specific adapter pair can be produced on-site after patient hospitalization, much like patient identification barcodes.

Keyword

Medication Error; Syringes; Catheters; Printing; Three-Dimensional

MeSH Terms

Catheters
Hospitalization
Humans
Medication Errors*
Syringes
Tooth

Figure

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  Fig. 1 Safety injection system. (A) Detailed schematic of safety injection system and (B) operational schematic of safety injection system.

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  Fig. 2 Adapter design for safety injection system. (A) A syringe adapter, (B) a catheter adapter, and (C) their connections under the matching and mismatching conditions.

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  Fig. 3 Design of the syringe adapter. (A) Optical image of the syringe tip and (B) the corresponding 3D model of the syringe adapter.

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  Fig. 4 Design of the catheter adapter. (A) Optical images of the syringe tip and catheter injection-port, and their corresponding (B) 3D-scanned images and (C) re-drawn cross-section images showing the measured dimensions. (D) 3D-reconstructed images obtained with the syringe tip and catheter injection-port. (E) 3D model of the catheter adapter.

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  Fig. 5 Scheme for pattern and code generation. (A) Region code: three regions are assigned through the periphery of the circular end of the adapter. (B) Position code: ten distinct positions are assigned in each region. (C) Shape code: three distinct shapes of a tooth are assigned to be located in each position. (D) Example pattern and its corresponding code in the syringe adapter. (E) Example matching patterns formed in the syringe and catheter adapters.

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  Fig. 6 Adapter pairs of 36 distinct codes prepared in this study.

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  Fig. 7 Adapter characterizations. (A) 3D models and (B) their corresponding optical images of the example adapter pairs (code: 6R2L9M). (C) Assembly of the adapters with a syringe tip and catheter injection-port.

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  Fig. 8 Performance of the safety injection system. (A) Connections of the adapters under the matching and mismatching conditions and (B) liquid injection under the matching and mismatching conditions.

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