Sure-Fire Ways to Prevent Medication Errors

Patient Safety

By: Sheldon Sones

Published: 4/10/2011

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Proper labeling and effective communication leave zero doubt about the identity of drugs on the sterile field.


Problems associated with the mislabeling and mishandling of medications continue to plague surgical facilities. Besides being (very) specific requirements of CMS, proper medication labeling and clear communication ensure the right drug is given to the right patient at the right time. Let's review some of the ways you can minimize medication errors associated with inadequate labeling.

Set expectations
The tenets of proper labeling expectations include noting the drug, the drug's strength, date, time and initials or signature of the preparer. Failing to follow these national labeling standards exposes patients to unnecessary and preventable adverse consequences.

Done correctly, labeling ensures the right dose is administered when your staff has access to multiple strengths of the same drug, keeps your facility in compliance with drug expiration timelines, makes sure the person who prepared the drug is accountable for its safe administration and challenges the potential delivery of a medication by someone other than the individual who prepared it.

Make sure your staff is aware that every syringe or drug container that reaches the sterile field must carry labels that clearly note the drug's name, strength of dose per volume, the date the dose was mixed, the time it was prepared and the preparer's name or initials. Noting the date on prepared syringes ensures medications will not be carried over from one work day to the next. If you don't opt for manufactured, pre-printed labels, be sure the labels and markers employed bedside are indicated for use in the sterile field.

Does Labeling Really Matter? Ask This Hospital

Seven years ago, unlabeled medication vials in the OR had deadly consequences at Virginia Mason Medical Center in Seattle, Wash. The surgical staff there mistakenly injected Mary L. McClinton (right) with chlorhexidine instead of a local anesthetic. Both were colorless and clear and the receptacles containing the liquids were unlabeled, according to Tracey V. Jones, RN, the perioperative educator at VMMC.

Here are the improvements the facility made to its medication labeling policy and procedures in light of the tragedy. See if you can apply the lessons VMMC learned the hard way to improve your current medication safety protocols.

  • Announce. The circulating nurse must verbally identify medications delivered to the sterile field and show the label to the scrubbed assistant (tech or nurse) for confirmation.
  • Verify. Confirm the name of the medication, its strength or dosage and expiration date (or time if it expires in less than 24 hours).
  • Compare. The assistant and circulating nurse must confirm that any pre-printed syringe labels match the label on the medication's original source container.
  • Label. The assistant draws medications into syringes and immediately labels the syringes before verifying with the circulating nurse that the labels match the medication vials and original source containers.
  • Verbalize. Before passing filled syringes at the sterile field, the assistant re-checks the label and verbally verifies the contents. This should be done every time medications change hands.
  • Track. Keep a running total of the medication used during a case and be sure the amount is noted in the patient's operative report.
  • Differentiate. Place similar looking solutions in unlike labeled containers.
  • Simplify. Add only 1 medication to the sterile field at a time.

A spokeswoman for the medical center says safety improvements also include standardized labels for all anesthesia drugs that are available at point-of-use in induction rooms and on all anesthesia carts. In addition, standardized and sterilized drug label sets are available for all anesthesia blocks and for scrub techs to use on their back tables. The center has also implemented a "mystery-shopper" audit program to ensure all drugs are labeled correctly, and mandates staff confirm that all drugs and solutions in syringes or basins are properly labeled during pre-procedure time outs.

— Daniel Cook

Differentiate similar drugs
Drugs that look and sound alike increase the potential for medication errors. One effective and basic strategy for avoiding miscues is to store look-alikes in sections of drawers, cabinets or carts that are not adjacent to one other. Also try to limit storage of drugs to single strengths in order to avoid confusion. Use Tall Man letters to differentiate the confusing parts of similar looking medications. For example, write "EPHedrine" and "EpINEPHrine" or "HydrOXYzine" and "HydrALAzine" on labels to make the differences between these similar drugs obvious. A great resource for Tall Man lettering guidance is the Institute for Safe Medication Practices' complete list of confused drug names (www.ismp.org/tools/confuseddrugnames.pdf).

Consider affixing brightly colored labels to potentially commonly confused drugs that ask staff to pause and think twice before reaching for the intended medication. Place signage on the storage bins of drugs that could cause serious harm if given in error. Your staff must be overly cautious when reaching for these dangerous medications. (Again, check with the ISMP for a list of high-alert drugs: www.ismp.org/tools/highalertmedications.pdf).

In addition to storing look-alike/sound-alike medications away from each other and using Tall Man lettering on their labels to highlight the differences between them, take a few extra moments bedside to confirm that the right drug is administered.

When receiving drug administrative orders, write down the directives and repeat them back to the giver. Obviously, writing down orders won't work when medications are needed during emergencies, but still take the time to repeat orders back to physicians before administering the requested drug.

AORN's Medication Safety Tips

The Association of periOperative Registered Nurses' statement on safe medication practices outlines your responsibilities for protecting patients from dosing errors. According to AORN, the standardized protocols you implement should be guided by these essential elements:

  • Match medications delivered to the sterile field with the operating physician's preference card.
  • Read aloud the medication, strength and dose off of labels whenever passing medication containers to another member of the surgical team.
  • Use the digit-by-digit technique when verbally confirming drug orders. For example, say "one-two" instead of "twelve."
  • Whether you use labels developed in-house or manufactured labeling products, label all medications and medication containers on the sterile field, even if only 1 drug is used during a case.
  • Apply the same stringent labeling practices to chemicals and reagents on the sterile field as you would to medications.
  • The circulating nurse must verify verbally and visually with the scrubbed assistant or operating physician the name, strength, dosage and expiration date of all medications delivered to the sterile field.
  • Prepare, verify and deliver a single medication to the sterile field before repeating the process for other needed drugs.
  • Throw away any unlabeled medication or solution found on the sterile field.
  • When new staff enter the OR to relieve surgical team members, both parties must review and confirm all medications present on the sterile field.
  • Keep all medication containers used during a case in the OR until the conclusion of the procedure.
  • Have a qualified nurse or other practitioner double-check all medication calculations.

— Daniel Cook

Manage multiple-dose vials
Today, multiple-dose vials are commonly used only when single-dose products are unavailable. Shortages and recalls of key drugs might force you to consider using multiple-dose vials more often than you'd like.

Wipe multiple-dose vials vigorously with alcohol swabs and friction, before re-entering them and store the vials in strict accordance with manufacturers' guidelines (some call for refrigeration of their products). Other vials, such as those filled with succinylcholine, can be stored at room temperature, but only for a specified amount of time (14 days in the case of succinylcholine).

Multiple-dose vials remain acceptable for use 28 days after the first entry, unless the manufacturer's expiration date occurs first or a specific product designates a shorter timeline. Note the expiration date on the vials instead of when they were opened, so the notations match the other products' in-date status labels in your drug storage areas.

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