Letter from the Editor

What's in a Label? Avoiding Medication Mistakes

Morton Kern, MD
Morton Kern, MD

Your patient requires heparin. The nurse picks up a brown heparin vial from the back counter, silently draws up the requested dose and gives it to the patient. The dose was supposed to be 1,000 units per kilogram, but 10,000 units per kilogram were given. Although there was no immediate injury, the hospitalization was prolonged, and no significant harm was done. After discharge from the hospital, the family brought legal action against the manufacture of the medication bottle for mislabeling but did not blame the nurse or the hospital. Whose problem is this?

The Problem of Medications in the Cath Lab
In the cath lab, multiple medications are always on the table in syringes and cups. The Joint Commission Accreditation on Health Care Organizations (now Joint Commission) requires that every syringe or container of any liquid or medication have a label, including the waste bowl, the bowl in which catheters are stored and any receptacles for other medications. Every cath lab physician, nurse and technologist has at one time or another has picked up a syringe, which they assumed to contain one medication and found it to have something else inside. Administration of the wrong medication is a critically important error which we seek to avoid at all costs. In order to do this, we have always employed a system of labeling, now formally mandated for all cath labs.

Who is Responsible for Correct Medication Administration?
This is the first and most important question. In this scenario above, who is responsible for medication administration and correct dosing? The answer is the physician and the nurse. The trained individual who draws up the medication, and the individual requesting that the medication be given, namely the physician, control what happens to the patient. It is mandatory that every person administering medication correctly identify the medication, calculate the dose and administer the medication via the appropriate route.
Labels on medication bottles may be difficult to read, but this does not eliminate the need for accuracy. If there is a problem with reading the labeling on the bottle, many laboratories will take on the task of clarifying the contents of the bottle and its label for nursing usage. Regardless of whether medication bottles have clear labeling or not, it is still the responsibility of anyone handling medications to read the vial, double-check the contents, concentration and route of administration with the requesting physician. Part of the laboratory’s routine should be to repeat the order out loud so that all can hear and confirm. Remember, communication really does solve problems, and improves accuracy and performance.

Labeling as the Answer?
In our laboratory at this time, all the labels are white, printed with small black letters indicating the contents of the syringe or container. For example, these labels would state normal saline, 0.45%; lidocaine, 1 mg per milliliter; nitroglycerin, 100 mcg per milliliter, and so on. Unfortunately, all the labels appear the same in the dim light of the cath lab (to me) and if labeled syringes are dropped in the sterile field, these syringes can easily get lost among the saline syringes. It is clear a better system needs to be implemented to avoid medication errors.

One Solution to the Labeling Problem
My preference is to attach colored labels to any medication syringe or cup. In addition, several companies make color-coded syringes with colorful pistons and printed names on the barrels. In the cath lab, it is difficult to read small lettering, due to a number of very good reasons (such as dim light, small type, old eyes, etc.) The similar small-size font and style of black-on-white labels can lead to confusion.
However, this issue of colored labels does not have universal consensus. Some hospital pharmacies recommend avoiding colored labels, believing that depending on colored labels is also a source of error, as colors may indicate different things in different places. Since there is no foolproof system when human beings are involved, any system designed to reduce misidentification should be considered and implemented. For labels, I believe color-coded is better than black and white. Now to the question of who is at fault? Is it the physician, the nurse, the hospital or the manufacturer of the medication bottle? I think that the manufacturers do a fair job at labeling the contents of their bottles. Some manufacturers may not label well, but the use of medication always remains in the hands of the user. Liability is an issue for the courts, but common sense would suggest that those of us who use these products are well-paid, well-educated and responsible people. We all take our job seriously, and would agree that any way we can prevent errors and protect our patients requires a continuous critical reappraisal and keeping it as a top priority.

My thanks to Laura Minarsch, Celia Chao, and David Pound for their inspiration in this topic.