Anesthesiologist Peter Baek is so lazy he’s efficient. He hates taking the long way around a problem, and would rather find an easier, more direct way to get something done. Otherwise, he may not do it at all.

And, in the past, when he didn’t do something, it almost spelled disaster.

In 2013, he was in an operation and grew confused. He was unsure which drug was which on the anesthesia cart. He hadn’t labeled the syringes that were to be administered to a patient. He almost gave his patient the wrong drug.

Baek was shaken.

But, sadly, he was not alone.

In some operating rooms at hospitals across the country, syringes are strewn across the anesthesia cart, labeled to varying degrees with what the American Society of Anesthesiologists (ASA) and Joint Commission for Accreditation (JC) deems required items. Those required items are the drug’s name, its strength, the expiration date if it is not used within 24 hours, and the expiration time when expiration occurs within 24 hours.

In a 2011 study at Tulane University School of Medicine in New Orleans, syringes were collected from ORs on three random days over four months. Researchers gathered 279 syringes. Six of them were pre-labeled from the manufacturer and not included in the study. Of the remaining 273 syringes, 101 of them were unlabeled. Researchers were unable to determine whether they had been used to administer drugs, so they examined the data with and without the unlabeled syringes.

Of the 273 total syringes, 62% only included the drug name. 12% included the drug’s strength. 1.5% included the amount of drug drawn from the vial. 1.1% included the time the drug was drawn. 4.4% include the date. 4.4% included the provider’s name; and 37% had no label.

“Of the 273 syringes in this study, 0% was in compliance with ASA/JC syringe labeling standards,” the researchers wrote.”Considering that ASA/JC standards expect 100% compliance with regulations, our findings indicate that provider compliance is significantly lower, both when considering all syringes and considering only the labeled subset of 172 syringes, to assess whether labels were significantly incomplete.”

Baek knew the guidelines established by the U.S. Pharmacopeia (USP), Centers for Medicare and Medicaid Services (CMS)ASAASTM and Institute for Safe Medication Practices (ISMP). But he, like most anesthesiologists, wasn’t really following all of them. The method of writing data by hand on labels, for instance, seemed antiquated and silly.

And, in the OR, things can happen fast in some cases, requiring the need for a quick draw and administration of drugs.

Taking all of these things into consideration, Baek knew other anesthesiologists were almost making mistakes, and some probably were. Baek, who served as an anesthesiologist at Joint Base Andrews in Maryland, learned at the base to only give orders he was prepared to follow. So, unless he wanted to follow antiquated procedures, he could not direct others to do so.

That’s when he decided to find an easy solution for himself. It came with one caveat: Safety would not – and could not – be sacrificed. And so Baek founded Vigilant Solution to provide an efficient way to make compliant labels for syringes. With a simple scan of a barcode on an anesthesiologist’s badge, the labels for a case are printed, ready to be adhered to syringes. The labels include the drug name, its concentration, the date and time it was drawn and the user ID of the provider.


Shortly after Baek founded Vigilant Software, he and others realized the great need for the system. An anesthesiologist at another hospital didn’t label a syringe and administered the incorrect drug to a patient at the wrong time. The patient crashed out. The hospital knew it had to act. It looked at potential solutions to ensure it didn’t happen again. Ultimately, it selected Vigilant Software as a labelling system to ensure patient safety and compliance.

The hospital chose Vigilant Software because leaders thought it was what would be adopted the easiest and most quickly by the anesthesia team. They were right.

As time went on, Baek learned something interesting: Hospitals that were using Vigilant Software were reporting increased revenues and a decrease in lost claims. That’s because some of those medications used in the OR may not have been entered into a patient’s EMR – or they may have been entered incorrectly – before the hospitals installed Vigilant Software.

In the OR, anesthesiologists are working with a backward workflow. They draw medication, administer it and then it is up to them to enter it into a patient’s electronic medical records. This is counter to what happens in the rest of the hospital as patients are given drugs.

With so much going on in the OR as anesthesiologists safely bring a patient out of anesthesia, transfer them to the PACU and prepare for a next case, they may overlook putting medications into EMR. And, that means the patient or their insurance company is not billed for them. This can cost the hospitals thousands of dollars. And, Vigilant Solution’s clients have increased their revenues by hundreds of thousands of dollars.

While Baek invented his system solely to make things easier for himself while ensuring optimum patient safety, he had no idea how much money it would save hospitals. In retrospect, as he was being “lazy,” he was being the smartest person in the room. His laziness created efficiencies that were pure genius

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