Accreditation

Eight expert tips for medication labeling success

Briefings on The Joint Commission, February 1, 2006

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Cases of unintentional medication and solution swaps are widely covered in the media. Unfortunately, many of these cases are devastating and result in fatal complications. They include

  • high-concentration epinephrine mistaken for low-concentration epinephrine

  • Formalin mistaken for spinal fluid

  • prep solution mistaken for radiocontrast dye

  • muscle relaxant mistaken for antibiotic

    Despite the frequency of cases, the Institute for Safe Medication Practices reports that during a 2004 survey of 1,600 hospitals, only 41% reported that they consistently label medication containers (e.g., syringes and basins) on the sterile field. Although it has increased from the 25% reported in its 2000 survey, 41% is a far cry from even half of the hospitals reporting.

    A new JCAHO National Patient Safety Goal addressing this topic took effect January 1. The goal requires hospitals to label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off of the sterile field in perioperative and other procedural settings.

    Extension of the five 'rights' of medication use

    This goal reaffirms the five "rights" of medication use. In other words, staff ensure that they have the right

  • patient

  • medication

  • dose

  • time

  • route

    However, the following pitfalls may occur and lead to poor habits:

  • Assuming that the medication is correct

  • Submitting to production pressure

  • Relying on memory

  • Normalizing deviance

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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