MISLABELED VIALS It's the little things that can lead to big medication errors in the perioperative setting.

Let's see how high you score on this medication safety quiz. Some of these questions are tricky. Read each carefully. Just like look-alike medications, everything's' not always as it seems at first glance.

Q Do we have to label a syringe that's drawn and then not laid down before it's injected into the patient?

A No. If a syringe is drawn and then not laid down, it doesn't require labeling. So, for example, if the anesthesiologist draws up propofol and then turns and injects the propofol into the patient, you wouldn't have to label that syringe. Conversely, if he places the syringe down and it's not for immediate use, then it must have all of the required labeling elements.

PROBLEM WITH PRE-LABELING SYRINGES This photo shows that someone placed an "atropine 0.4mg/ml" label on a syringe, but the vial indicates that atropine 1mg/ml is about to be drawn into it.

Q Is it okay to pre-label syringes — to label a drug as added before the actual addition?

A No. Pre-labeling a supply of syringes long before they're filled with the indicated agent is not a safe practice, as it potentially sets the stage for someone to use the wrong syringe for a newly drawn medication. In my consulting visits to surgical centers over the years, I've seen a sealed BSS bottle that already contained a label indicating epinephrine had been added and anesthesia carts filled with empty, pre-labeled syringes.

Q Is it okay to "stretch" prefilled syringes by withdrawing portions of contents of the drugs they contain?

A No, it's not advisable to withdraw medications from prefilled syringes. It's understandable that you want to prevent drug waste, but using cartridges as multidose vials is a risky practice. These products are not intended to be multiple dose vials. What's more, transferring medications from one syringe to another is a risky process that could cascade into errors, possible needlesticks and contamination.

Q What are the 5 required elements for drug labels for pre-drawn medications?

A Drug name, strength, date, time drawn into syringe and initials of preparer.

Q How do you compute the expiration date for multiple-dose vials?

A Use this formula to compute the expiration date for multiple-dose vials: expiration date = today + 30 — 2. Note the expiration date (28 days or the manufacturer's date, whichever occurs first) rather than the "open date." As a rule, however, you should minimize the use of multiple-dose vials.

TOO CLOSE FOR COMFORT The labels for cefazolin and ampicillin are awfully similar.

Q Where should we store medications with similar-looking labels?

A As far away from each other as possible. That's the short answer. Some manufacturers' labels, such as those for cefazolin and ampicillin, are too close in appearance and can therefore cause confusion when staff read them quickly. Medications that can be used for similar therapeutic purposes also increase the potential for error. Be sure to store medications with similar-looking labels far away from each other. Some manufacturers minimize the potential for errors by using more distinct labeling, such as "tallman letters" — EPHEDrine and EPINEPHrine — to help prevent errors with look-alike/sound-alike drug names.

Q What should my formulary list look like?

A While there is no "law" on the format of the formulary, I suggest the following to ensure that this document is not just for compliance, but has a functional value to the prescribers and nursing staff.

• Generically list all drugs alphabetically
• Place the "trade name" in parenthesis after the generic name. For example: epinephrine (Adrenalin).
• Note strength and dosage. For example: propofol (Diprivan) 10 mg / ml vials, 20 ml

Q Look closely at this box and tell me what's wrong.

A It's helpful to mark boxes with the expiration date, but in this case the date was wrong. It should be 10/11.

Q Can you find 3 things that are wrong with this electronic thermometer?

A The temperature should be 36 to 46 ?F (it was 49 ?F); the high and low wasn't set for 36 to 46 ?F; and the alarm was in the "off" position.