Earlier versions of the template that we created were complicated,
making it more restrictive and harder for providers to use effectively.
After more than a dozen redesign attempts, we came up with the final
product. It features:
• Assigned locations. Syringe wells designated for 3 critical emer-
gency medications (epinephrine, atropine and succinylcholine) are on
a raised platform in the upper right corner of the template to
sequester and standardize their locations, and to make them easier to
identify and grab. Additional surface-level wells are labeled for opi-
oids and neuromuscular blockers (medications that could prove
harmful if used inappropriately) and antibiotics (which we had issues
with being swapped with opioids and muscle relaxants). All of the
designated wells are outlined in color-coded lines according to drug
class. We included an additional well in the upper left corner of the
template where providers can place syringes filled with medications
that they deem to be high risk.
• Free space. Half of the template's surface area is unaffiliated and
where providers can place medications of their choosing. We included
horizonal lines to act as guides based on our general recommendation
to line up filled syringes horizontally in order to make their labels eas-
ier to read. We also suggest differentiating flush syringes by lining
them up along the vertical lines on the left side of the template.
• Easy maintenance. The template is made of non-porous plastic and
features smooth corners, making it easy to clean between cases with
germicidal wipes. It's also durable; ours has lasted 6 years and shows
no signs of wear and tear.
What made our efforts at improving medication safety unique was
the access we had to very smart people at the nearby University of
Washington, including interaction design expert Axel Roesler, PhD,
MFA. Dr. Roesler's design acumen and non-clinical perspective helped
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