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Lessons in Medication Labeling
Delivering the right dose at the right time starts with knowing which drug you're dealing with.
Richard Novak
Publish Date: September 20, 2013   |  Tags:   Supply Management
color-coded labels ◙ STICKER STOCK Pre-printed, color-coded labels are easy to read and apply.

Anesthesia providers are surgery's solo pilots. They decide which drugs to inject without consulting another member of the surgical team. Busy providers might care for 700 patients over the course of a year, delivering 10 different drugs per case. If their careers span a quarter century, they'll administer 175,000 medications. Anyone with a basic understanding of odds and an appreciation of the human condition will realize that you can't fully eliminate medication errors. But we can limit the risks, which starts with properly labeling all medications.

What should labels note?
The American Society of Anesthesiologists says all medication labels on vials and ampoules must contain the drug's generic and commercial names, concentration, total volume or contents, manufacturer, lot number, date of manufacturing and expiration date. Bar codes containing this information must not interfere with the label's legibility. A label's font must be easy to read and extra spaces should separate the drug name from the other information.

Providers must note the drug, strength, date, time drawn and their initials on syringes or containers that reach the sterile field. "Tall-man lettering" can be used to highlight the initial or distinctive syllables in similar looking drug names. Providers should be able to clearly write information on the label's material, using a ballpoint pen or felt-tip marker without it smudging or running.

To make labeling easy and accurate — and to ensure the labels are easily read — consider using pre-printed labels on syringes in non-sterile fields. These labels match the ASA's color-coded drug classifications: induction agents are yellow, benzodiazepines are orange, muscle relaxants are fluorescent red, narcotics are blue, vasopressors and hypotensive agents are violet, and local anesthetics are gray.

Peel-off labels on vials can be applied to single-use syringes when the vials' contents are drawn. Ensure medication names are still visible on the vials after the peel-off labels are removed.

Read carefully
Bar-code technology can improve the accuracy of drug administration and help the reporting and tracking of wrong-dose errors. These high-tech solutions are not widely used in operating rooms in 2013, however, so providers and surgical teams must rely on more conventional solutions when administering meds: attention to detail and extreme focus.

Carefully review the labels on ampoules or syringes before drawing or injecting medications. Always label syringes when drugs are drawn into them, and be sure to keep workspaces clean and organized.

Labeling syringes is not required when placing a spinal or epidural block under sterile conditions and without a break in the process, according to the ASA, which suggests the potential for error is miniscule because the drugs are never out of sight or control of the provider and are administered immediately.

Anesthesia's 7 Deadly Drugs

high-risk medications ◙ PREFENTIAL TREATMENT Store high-risk medications away from the general drug population.

The importance of administering the right dose to the right patient at the right time is heightened when dealing with these potential killers.

Epinephrine (1mg/1ml ampoule) is used during sudden cardiac arrest to treat asystole and refractory ventricular fibrillation and anaphylaxis. It can also be used to treat decreased cardiac output. If accidentally injected into a healthy patient, it will immediately cause major hypertension and tachycardia. The drug can be lethal in elderly patients or individuals with diminished cardiac reserve.

Phenylephrine (10 mg/1ml ampoule) effectively treats hypotension when injected in 100mcg doses or used as a dilute infusion. When injected in error, it causes major hypertension and reflex bradycardia, and can be lethal in elderly patients or patients with diminished cardiac reserve.

Nitroprusside (50mg/2ml) is used to treat hypertension. If it's injected without first being diluted, the patient will experience rapid arterial vasodilation and severe hypotension.

Insulin (100 Units/1ml, 10ml vial) is used to treat hyperglycemia, with typical doses ranging from 5 to 30 units. Overdosing an anesthetized patient will result in severe hypoglycemia and brain death.

Potassium chloride (20mEq/10ml) is used to treat hypokalemic patients. If administered erroneously as a bolus, it can cause severe ventricular arrhythmias and death.

Heparin (1000U/ml) is an important anticoagulant, used routinely in open heart and vascular surgeries. It can cause unexpected intraoperative bleeding if administered in error.

Isoproterenol (1mg/5ml) can be used as a dilute infusion to increase heart rate in critically ill patients. When injected in error, major tachycardia and hypertension will occur. It can be lethal in elderly individuals or in patients with diminished cardiac reserve.

— Richard Novak, MD

Segregated storage
In a confidential survey, private practice anesthesia colleagues of mine admitted to mixing up these drugs at some point in their careers: pancuronium instead of neostigmine; mivicurium instead of midazolam; atracurium instead of atropine; epinephrine instead of naloxone; epinephrine instead of ephedrine; and metoclopramide instead of neostigmine.

What can you do to prevent potentially devastating consequences when managing essential but dangerous medications (see "Anesthesia's 7 Deadly Drugs")? Insulin, for example, is typically stored in an OR refrigerator, away from commonly used drugs. Many facilities also have protocols in place requiring that 2 caregivers confirm the accuracy of insulin doses before injection.

However, other high-alert medications are often mixed in with the general drug population. One hospital I work at stores ampoules of isoproterenol in the routine drug drawer, next to ampoules of often used medications such as ketorolac, hydrocortisone and promethazine.

I recommend removing major vasopressors (epinephrine, phenylephrine and isoproterenol), the major vasodilator nitroprusside and the potent anticoagulant heparin from common drug drawers. Above all, anesthesia providers must carefully read labels when preparing any injections, especially when holding a syringe filled with one of the 7 deadliest drugs.

Don't store look-alike and sound-alike drugs in adjacent bins or drawers. Separate pediatric and adult doses and various concentrations of the same medication, as well as different drugs that come in similarly shaped vials or have nearly identical labels. Consider storing drugs in non-alphabetical order to further avoid the possibility of selecting the wrong vial. Affix warning stickers to the bins or labels of often confused drug names (ismp.org/tools/confuseddrugnames.pdf) so providers and staff stop to ensure they're pulling or administering the right medication or dose.

Can EMRs Cause Medication Errors?

EMRs cause errors ◙ TECHNICAL DIFFICULTIES Default settings may put patients at risk.

Electronic medical records are supposed to help prevent medication delivery errors, right? Not necessarily, says a report in the September issue of the Pennsylvania Patient Safety Authority (tinyurl.com/lpbb8nl).

EMRs' default modes, which preset medication dose and delivery information, are used to improve standardization and efficiency in healthcare facilities. For example, a recovering surgery patient might receive a dose of a certain pain medication, as indicated by the system's default mode.

According to the report, most EMR-related medication errors are linked to staff failing to change default settings or entering incomplete dosing information, and systems overwriting user-entered values.

Erin Sparnon, MEng, patient safety analyst for the PPSA, advises EMR users to review how they enter dose time information, ensure default values keep up with changes in clinical practice and determine if their systems clearly indicate the difference between user-entered data and system-entered data.

— Daniel Cook

Why security matters
Keeping controlled substances secure is an important aspect of medication management.

The ASA mandates that all controlled narcotics be kept in locked, enclosed areas when not under the direct supervision of an anesthesia provider. Because the OR is a limited-access location, says the ASA, providers can leave non-controlled medications unattended on anesthesia carts or anesthesia machines for brief periods (as long as it would take to bring a patient into the OR from the pre-op area, for example) provided there are authorized personnel in the OR during that time.

Emergency drugs such as dantrolene must be kept in a secure and dedicated cart or kit, according to the ASA. These storage solutions must be easily accessible by providers or authorized staff. Combination or key locks are not recommended, since the seconds wasted trying to find the key or the individuals who know the access code could jeopardize lifesaving efforts.