To the Editor
Standardization of the look and feel of supplies and equipment plays an important role in achieving a safe environment for patients. A supply substitution in our OR resulted in the inventory placement of a stopcock which has a significantly different tactile and visual appearance when the side port is closed. This difference led to a period of delayed therapy when a medication infusion was inserted into the side port of a stopcock which was thought to be open, but was closed. The infusion pump occlusion alarm sounded and visual inspection of the fluid path did not initially reveal the point of occlusion. Only after additional troubleshooting was the closed stopcock identified as the source of the occlusion. Careful examination of any new equipment, even equipment which appears to be similar to existing standards is necessary to ensure that the function matches what is expected.
Paul St. Jacques, MD