Safety in colours: using colour to communicate drug error in the anaesthetic and critical care settings

Abstract

Background: Drug error is a persistent problem in global healthcare with little in the way of ‘production to patient’ safety innovation.1–6 Most safety adjuncts in the anaesthetic setting are user applied, do not guarantee the syringe contents and rely entirely on the lead practitioner. We propose that tinting drugs using colour code ISO26825:2020 could contribute to a reduction in drug error. Methods: We asked (n=20) anaesthetists about drug errors, or near misses, with which they had been involved. We evaluated which of these involved drugs which would have been of different colours if they had been tinted using colour code ISO26825:2020. We also conducted a Quality Improvement Project investigating using tinted drugs in an anaesthetic simulation scenario and its impact on work speed and number of syringe touches (n=17). Results: Twelve out of 21 of the drug errors or near misses cited by (n=20) anaesthetists questioned involved drugs of different ISO26825:2020 classes and would have been tinted different colours according to our proposed intervention. Participants (n=17) using tinted ‘Safety in Colours’ drugs completed the simulation on average 7 s faster than participants using current practice colourless drugs. Participants using tinted ‘Safety in Colours’ drugs on average touched two fewer syringes in their drug tray at the end of the scenario compared with participants using current practice colourless drugs. Participants favourably scored using Safety in Colours drugs in terms of safety, speed, and working practice when compared with current practice. Conclusions: This is a proof of concept study and the results suggest further research is warranted. Our preliminary findings show suggestive evidence that tinting drugs using biocompatible dyes is acceptable to healthcare workers in the anaesthetic and critical setting and may contribute to an improvement in work efficiency and improved touch accuracy which could translate to a reduction in drug error.