When Jean Snyder, DNAP, CRNA, read a story about a vibrant boy who went in for routine surgery and instead of coming home, died during, she knew she had to do something. The cause of the child’s death was a medication error. “As a mother and as a nurse anesthetist, my heart grieved for this loss. I knew that if we had a safe means to keep our syringes and vials, the mistake may have been recognized earlier, and perhaps that child may have had a different outcome,” says Snyder, owner of Jean F. Snyder CRNA Inc. and co-owner of Goodwin and Snyder Anesthesia Associates, PLLC, who also works full-time for Bon Secours DePaul Medical Center. “I knew I had to invent ERMA [Error Recovery and Mitigation Aide].”
“I developed an ERMA prototype in 2008 but had no means to refine and market it. In 2016, as part of my doctoral program at Virginia Commonwealth University, I wrote a whitepaper discussing medication errors within the context of error critical systems. ERMA was a means to provide early recognition and, hopefully, mitigation of medication errors. I then submitted my whitepaper and prototype to Innovation Institute, a medical device incubator that is affiliated with my hospital system. Innovation Institute worked with me to refine ERMA and obtained a provisional patent. We are presently working to market ERMA,” states Snyder.
Snyder explains what ERMA is and what it does:
“ERMA is a clear reservoir inserted between the re-entry proof top and opaque terminal disposal portion of a traditional needle box. It allows a practitioner in any high-risk area (OR, ED, ICU) to have visualization of all the syringes and vials used during the course of a procedure, anesthetic or surgery. At the end of a single procedure, a trap door in the bottom of the reservoir is released to allow those sequestered vials and syringes to drop into the bottom of the needle box for terminal disposal. Providers now have a means to refer back to any medication delivered for an individual patient. ERMA allows us to recognize errors in a timely fashion and address the untoward events that may arise from the error in a timely fashion.
“Research has revealed that medication errors occur despite concentrated efforts to prevent them partly because medication administration has become increasingly complex. In addition, providers are distracted, tired, [and] 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 are eliminated as one person prescribes, prepares, administers, and charts the medication. A single anesthetic often administers several doses of up to 20 medications. 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 a second chance—a method to make 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 that would have been spent in trying to figure out the precipitating cause of the medical crisis.”
Some of the biggest rewards that Snyder has had in inventing the ERMA is that she has learned she has both the heart and mind of an inventor. In fact, she says that she’s already given two more ideas to the Innovation Institute and already has others “simmering on my backburner.”
Her biggest reward, though, hasn’t happened yet. But she hopes it does. “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 meeting the mother that lost her child to tell her that her loss was 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,” says Snyder.
She also has advice for other nurses who have good ideas about improving something in health care. “I believe all nurses are inventors at heart. We develop workarounds every day at work. We innovate every day. We don’t have the power and means to move our ideas to reality. My advice is to find a mentor. I have some amazing mentors at Bon Secours, VCU, and Innovation Institute,” she says. “Read about other nurse inventors and reach out to them. By definition, nurses are nurturers and delight in the ideas and successes of our colleagues. Reach out to your hospital system to see if they are affiliated with a medical incubator. Google scholar and Google patent are amazing resources because sometimes your idea is so good, it has already been invented or patented! Read the research to look for inspiration.
“I encourage all nurses to innovate. Through nursing innovation, we will improve patient safety. Innovation is a positive feedback loop; as we innovate and take our places as experts in the medical field, administration will reach out to us as the experts.”
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