A milestone in patient safety

Celebrating a milestone in patient safety innovation

By Stephanie Brooks

Wilton Levine shares examples of the original SLS labels.

Since its introduction, the Codonics Safe Label System® (SLS) has helped prevent more than 2.1 million medication errors and supported over 70 million procedures. Installed in more than 17,000 operating rooms across 1,200 hospitals in 20 countries, the SLS has become the standard of care in perioperative and postoperative settings at many of the world's leading hospitals.

The SLS was developed by Massachusetts General Hospital Department anesthesiologists Wilton Levine, MD, J. Kenneth Davison, MD, and Nathaniel Sims, MD, together with their biomedical engineering colleague, William D. Driscoll, and a team of three additional colleagues at Mass General. It was designed with the goal of reducing human error during drug preparation and administration in operating rooms and intensive care units.

Development of the SLS was funded through the Sims Lab at Mass General, which had received a portion of patent licensing royalty revenue following the global, non-exclusive licensing of a patent for smart infusion pumps on which Sims is the lead inventor.

"I wanted to pay it forward by supporting new inventions from others in the Mass General community," Sims said. "I was interested in ideas from colleagues that addressed previously unrecognized problems or pain points. I was looking for front-line clinicians with early concepts for solutions, with the hope of helping build teams of engineers and collaborators and providing support or financial backing."

When Sims was approached by Levine and Davison, he knew it was the right project to champion.

Together with their collaborators at Codonics, they transformed their original concept into the SLS, a U.S. Food and Drug Administration-cleared medical device that provides visual and audible medication verification and prints full-color, Joint Commission-compliant syringe labels. The patents developed at Massachusetts General Hospital were licensed by the hospital to Codonics, which engineered and commercialized the SLS, and now manufactures, supports and distributes it globally.

Attendees also heard about the continued evolution of the SLS platform, including Safe Waste System™ (SWS), designed to operate with SLS. SWS uses a built-in spectrophotometer to analyze controlled substance waste at the point of care, automatically draws the waste into a non-retrievable container and creates waste-event data available for reconciliation and oversight.

"The celebration recognized the significant clinical and operational contributions of the original innovation team, several of whom continue to serve at Massachusetts General Hospital and remain active contributors to patient safety and quality improvement initiatives," said Levine, who now serves as vice president of Procedural Services and Clinical Affairs, Hospital Operations, for Massachusetts General Hospital. "The gathering also provided an opportunity to discuss continued innovation in medication management, future collaboration and lessons learned from successfully translating a clinician-driven idea into a technology solution that has benefited healthcare organizations nationally and internationally."

Driscoll, who now serves as executive director for Biomedical Engineering for Mass General Brigham, attended the event. At its conclusion, he said, "Thank you for bringing this group together for a wonderful celebration and reunion of everyone who contributed to a journey that began 20 years ago with an idea to solve a problem at one hospital. It evolved from a prototype and educational exhibit into a collaboration, and ultimately into a highly impactful safety product with impressive reach around the world. It continues to evolve and improve over time. It was great to reconnect and celebrate together."