WE CAN DO BETTER Careless medication errors kill up to 100,000 patients per year.

In my travels to ambulatory surgery centers throughout the country, I regularly see labeling and storage situations that could result in everything from minor mishaps to major catastrophes. Take a look at these photos I shot and see if you can figure out what's wrong with each. Hopefully, they'll serve as reminders to help prevent any similar occurrences at your facility.

1. ALL MIXED UP How much lidocaine is in this syringe? How much Marcaine? How much Wydase? It's impossible to tell. And whom would you ask? Whoever prepared the solution didn't bother to mark it with his initials, nor with the date and time it was prepared.

Those are the strengths of the medications you see, not the amounts of each. Careless preparation like this goes against just about every set of regulatory guidelines you can imagine, and it's been the root cause of many errors over many years.

2. SMALL PROBLEM These containers of BSS solution (an eye wash) have had epinephrine (a dilation agent) added, but it would be easy to miss that fact, because the added labels are small and are applied to the backs of the containers instead of the fronts.

Anyone holding the mixture should immediately see what was added, along with the date and time it was added, and the initials of who added it. (Unknowingly adding additional epinephrine could cause excessive dilation, or excessive duration of dilation.)

The date and time are key, because when admixing occurs outside of a laminar hood, as was the case here, it should be done no more than 1 hour from preparation to administration. Also, although the caps are reapplied, standard foil-wrapped-type labels are recommended.

3. IN AND OUT Succinylcholine and Rocuronium are to be refrigerated, but once removed, they can be stored at room temperature for specific periods of time (14 days for Succinylcholine; 60 days for unopened Rocuronium, 28 days for opened Rocuronium). What you can't do is open them, use them, put them back in the fridge, take them out, use them again, etc. Here, the vials were opened, never dated, and appear to have been moving back and forth between refrigeration and room temperature.

Once they're removed from refrigeration, they should be clearly marked with either the manufacturer's expiration date, or the appropriate date based on when they were removed, whichever comes first. They shouldn't be re-refrigerated.

4. DOUBLE TROUBLE This one should make the hair on the back of your neck stand up. Not only has the syringe been left in the vial after being drawn, which should never happen, the vial says Fentanyl and the syringe is labeled Ultiva. The explanation given ("I just put the wrong label on it, I know what it is") doesn't come close to cutting it.

5. TOSS IT There it is in black and white: "Discard unused portion." This container was not discarded, however. Something else worth noting on the label: "No microbial agent has been added." The manufacturer is making it clear that there's a possible sterility issue once the container has been opened. That doesn't mean discard it at the end of the day, or even at the end of the hour. It means at the end of the case. Doesn't feel right to just toss it? Close your eyes for a moment and imagine you're the one on the table. Would you want a fresh bottle?

6. DON'T OPEN UNTIL … Contemporary consensus is clear: Syringes should not be unwrapped until they're needed — meaning as close to the time of administration as possible. No doubt, the anesthesia provider whose cart provided this photo figured it was a good idea to save time, but at what cost? Not only is there a general sterility issue here, in a situation like this, how much more likely is it that a used syringe might accidentally end up in the big pile of "good" ones?

7. SOUND ADVICE This one's very easy (and very dangerous). Accidentally storing drugs with similar sounding names (or even dissimilar names) in the wrong location can be catastrophic.

8. DON'T ASSUME Imagine you're a senior patient reading these instructions, and imagine your "medical IQ" isn't off the charts. Imagine further that you were a little groggy when you were given instructions. Would you consider getting the drops out of the way early every day — maybe 1 drop at 9 a.m., another at 10 a.m., another at 11 a.m., etc., so you don't have to worry about it later? I know of a situation where a patient taking 10mg of a heart medication 4 times daily was told simply to "double it." Does that mean take the medication 8 times a day? Or does it mean increase the dose to 20mg? He wasn't sure. I recommend being as specific as possible. Instead of "4 times a day," make it clear that you mean at 8 a.m., noon, 4 p.m. and bedtime (or whatever is appropriate).

9. SEPARATE UNEQUALS One of the hazards of persistent and reoccurring drug shortages is that sometimes you end up getting the drugs you need in different strengths. Look closely here and you'll see that vials of atropine, a very potent drug, are all being stored together, even though some contain 1mg doses, and some contain 0.4mg doses. It's not hard to imagine a patient ending up with 2.5 times the intended dose (or only 40% of the intended dose). Make absolutely sure you store different strengths of the same drug separately.

10. IT'S NOT CLEAR Apparently you can't believe everything you read. Fortunately in this case, it's pretty obvious that the label is wrong. But what if it weren't so obvious. What if that "water" container had Cidex or some other caustic, but clear, liquid in it, and it got sprayed on a patient? Granted, this isn't a medication issue (this container was spotted in a janitor's closet), but don't think that absolves you of responsibility if the worst should happen. It's a good idea to review labeling guidelines for housekeeping solutions and cleaners, too.