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Unlabeled container proves deadly for Seattle hospital patient

Hospital Safety Connection, December 9, 2004

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An unlabeled bottle of antiseptic cleanser killed a patient during a procedure on November 23 at the Virginia Mason Medical Center in Seattle, the Seattle Times reported. However, unlabeled items aren't uncommon in hospitals, the Times reported.

Fewer than half of 1,600 hospitals around the country said they always label syringes, basins, and other containers holding solutions used during surgery and other procedures, says the Institute for Safe Medication Practices, a national nonprofit patient safety organization. The same survey revealed that 18% of hospitals anonymously reported that they never or rarely label containers.

Use of unlabeled containers and confusion of various kinds of look-alike fluids played a role in patient deaths and injury for decades, Michael Cohen, president of the institute, told the Times. "It seems so basic, yet this unsafe practice is fairly widespread in US hospital operating rooms," he said.

"Mary McClinton died after being injected with antiseptic skin cleaner instead of contrast dye during a procedure for a brain aneurysm, a bulge in a blood vessel," the Times reported.

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