Syringe Labels Research Articles

Medication stewardship in the operating theatre in Malaysia: A quality improvement project.

A quality improvement project ('Safe Anaesthesia for ALL-SEAL') was implemented to reduce preventable medication errors and drug wastage in the operating theatre (OT) of a tertiary hospital. The primary objective of this quality improvement project was to prevent the incidence of medication errors, and the secondary objective was to reduce the wastage of unused drugs. A pre-intervention questionnaire and an audit survey were performed, and multidirectional interventions were designed post-survey. A post-intervention survey was conducted to evaluate effectiveness. The incidence of medication errors, including near misses, was assessed for root causes. Unused drugs drawn or diluted in syringes were recorded daily in each OT. The weekly drug orders and mid-week reordering frequency were also monitored. The data were reported as simple means and percentages. Ninety-eight anaesthesia care providers participated in the survey (72.4% doctors and 27.6% anaesthetic nurses). Pre-intervention, 76.1% of respondents had experienced medication errors during their practice. Common errors included misidentification of ampoules or vials (65.2%), miscalculation of dosages (65.2%), improper syringe labelling (56.5%), accidental drug omission (54.3%) and wrong prescriptions (39.1%). The main sources of errors were fatigue/overwork (80.4%) and a hectic OT environment (71.7%). Post-intervention, no incidents of medication errors were reported. In addition, there was a significant reduction in drug wastage. The SEAL project positively prevented medication errors and reduced drug wastage, which should be further validated in other clinical settings.

From personal experience of working in the UAE. Note to fellow practitioners

ResumeThe article attempts to tell about what the author saw in one of the UAE hospitals. This hospital is not an ordinary one, it belongs to the leaders in the Middle East. Cooperates with John Hopkins Medicine. As part of the work, visits by lecturers and specialists are held to conduct demonstration operations and train interns.The organization of work in the operating room is described, in particular, the division of duties of nurses is carried out. Practical performance of work duties, such as storing medicines, accounting for equipment, monitoring its condition, the organization of the workplace, labeling of syringes, etc.The lack of work is greatly helped by institution, which we do not have. Foreign word Supervisor. Usually a female person comes (they are less prone to sentiments), stands, observes and records. Cleaners and nurses have supervisors. They become the best and most advanced according to the specialty.Attention is focused on the elements of the JCIA system and their importance for the organization of safe work for both the patient and the staff. Some details of work duties that are not always known to us. What is Time Out and why does it exist.A lot of attention is paid to the operation of a fully computerized hospital. There are no paper medical histories (patient files) in the hospital. They are there, they are binders with a few sheets of paper, everything else is on the server. This server is used by several hospitals and affiliated clinics.The work of the anesthesiologist in and outside the operating room, the documentation and equipment at the disposal of the anesthesiologist are described. What access and to what documentation of the patient do certain doctors have (to diaries that are written in electronic form, to the results of all possible studies, pictures, ECG, conclusions, results of computer tomography and others). A template is filled out for the statement, and this is one of the few paper documents.Describes how the patient care system works during surgery. Many technical details are given. How to warm a patient in the operating room, which aspiration systems are used, etc. The author hopes that the article will be interesting for domestic doctors and nurses, and will also find the use of some of the examples given in practical activities.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events.

The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

A Pharmacy Quality and Internal Audit Program Promoting Continuous Survey Readiness with Medication Management Standards.

Showcasing compliance with Joint Commission Medication Management (MM) standards during accreditation visits is important, but it is equally vital to maintain a state of continuous survey readiness. This article describes a Pharmacy Quality and Internal Audit Program to promote continuous survey readiness and sustained compliance with MM standards. A comprehensive MM audit was developed to assess for compliance in all inpatient, ambulatory, and procedural areas that use medications, with each area undergoing the internal auditing process at least twice per calendar year. The audit is performed by an MM subject matter expert from the Department of Pharmacy and incorporates electronic chart review, clinical staff interviews, and observations of area-specific medication practices. Notable findings and recommendations are communicated to area-specific leadership. Institutionwide scorecards are compiled to track performance with MM standards, identify opportunities, and determine future focus areas to improve and sustain compliance. Results revealed consistent compliance (≥ 90%) with a majority of MM standards. These included hazardous medication management, controlled substances compliance, look-alike/sound-alike drugs, medication storage/security, and labeling of medication syringes. Several areas of opportunity were identified: awareness of high-alert medications and risk-reduction safety strategies, compliance with pill cutter standards, and therapeutic duplication of "as needed" medication orders. Subsequent implementation of corrective actions and mitigation strategies resulted in improved compliance rates from < 50% to ≥ 90% for awareness of high-alert medications and risk-reduction strategies, from < 60% to ≥ 80% for compliance with pill cutter standards, and from < 90% to ≥ 90% for therapeutic duplication of "as needed" orders. Establishment of a Pharmacy Quality and Internal Audit Program allowed for performance tracking, identification of compliance deficiencies, implementation of focused corrective actions, and promotion of continuous survey readiness with MM standards.

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation

BackgroundPatients in intensive care units are prone to the occurrence of medication errors. Look-alike, sound-alike drugs with similar drug names can lead to medication errors and therefore endanger patient safety....

Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study.

Anesthetic drugs are prepared and administrated without referral to the pharmacy or other medical departments. We aimed to assess the occurrence of anesthetic drug errors in Saudi Arabia. We also determined the contributing factors, reporting strategies, and clinicians' opinions of the preventive measures. We conducted a cross-sectional web-based survey study using a validated tool. A total of 300 anesthesia clinicians completed the survey (146 anesthesiologists and 154 anesthesia technology specialists). We measured descriptive statistics to describe the demographic characteristics and performed inferential statistics to examine associations and differences. Sixty-nine percent of respondents had experienced an anesthetic drug error at least once in their career. The two primary factors that caused drug errors were haste (60.3%) and heavy workload (60.3%). On syringe labeling, 56.3% withdrew the drug then labeled the syringe, and 43.7% labeled the syringe then withdrew the drug. The chi-square test revealed that clinicians who labeled the syringe first then withdrew the drug made errors more frequently (p = 0.036). The test also showed that clinicians with less experience had committed more errors (p = 0.015). On reporting drug errors, 77.7% of respondents identified the fear of medicolegal issues as the most common barrier to reporting errors. Respondents believed that double-checking the medication and color-coded syringe labels were the most effective strategies to reduce errors (82% and 64%, respectively). The Mann-Whiney U test revealed significant differences between the two specialties about their opinions of the preventive measures. There was a high occurrence rate of anesthetic drug errors in Saudi Arabia. Policymakers need to unify the syringe-labeling practice, and future research needs to focus on what makes a nonpunitive culture to encourage reporting errors.

COVID-19 Vaccine, Myths, and Facts

Coronavirus pandemic has taken millions of lives worldwide. There was a period with no hope, but as time passed, humanity saw hope in the form of the vaccine. The good news is there finally, as a result of a collaboration between scientists and pharmaceutical companies many vaccines have been developed and massive immunization programmes have been in effect. However, there has been some misinformation regarding COVID-19 vaccine formulations, uses, side effects, and effectiveness. Since the day of vaccine development, some people are excited to get vaccinated whereas others are afraid of having it. There are certain myths about the COVID-19 vaccine which as a researcher in the field of microbiology/immunology, I feel need some clarification. First of all, it is common thinking that the vaccine has been developed in less time and is still in phase three trials so it might be unsafe for clinical use. This is not true, the fact is that COVID-19 vaccine has gone through all the essential steps of vaccine formation and the same food and drug administration processes have been ensured for its safety and efficacy too.There are other myths too as if this vaccine contains a tracking device and it might change human DNA. Again there is no truth in it. There is an optional version of this product which contains a microchip within the syringe label; the purpose is to confirm the vaccine dose’s origin. The chip itself is not injected into a recipient of the vaccine. Similarly, a vaccine will not change DNA; its function is to build the immune system by creating antibodies against the antigen that is present in the vaccine. Another common myth is that vaccine has dangerous side effects. Well, common side effects like headache, myalgia, and chills have been experienced by the volunteers, however, severe allergic reactions were not observed in healthy individual volunteers. This is why people with a history of allergy to any drug, food, chemical, etc. have been excluded from the vaccine trials. Some other questions are also raised like vaccine may affect the fertility of women. The fact is that there is an amino acid sequence shared between viral spike protein and syncytin-1 (protein in the placenta), however, it is too small to initiate an immune response that can affect pregnancy. Another myth in people’s minds is that individuals, who have had a natural infection of COVID-19 disease, do not need to get vaccinated. Again the fact, as clear from evidence across the globe, clears that the natural immunity against COVID-19 does not last longer hence and it is advised to get vaccinated when it is your turn.It is also a common perception that wearing a mask is no longer needed once you are vaccinated. Wearing a mask, hand washing, and social distancing are required not only for COVID-19 protection, as well as these precautions, protect us from many other communicable diseases too. One important fact about COVID-19 vaccine is that no one can develop COVID-19 disease from the vaccine since it does not contain a live virus. However, it is possible to get infected with the virus before the vaccine has had time to protect human bodies by the formation of antibodies. Some other myths are also needed to be clarified here like people who have fewer co-morbid conditions do not develop severe symptoms of the disease, hence do not need to be vaccinated, the answer is simple, even if one is relatively safe, and one still can acquire and spread the disease to others. So it is important to get vaccinated.Another myth suggests that certain blood groups are least likely to develop severe symptoms of the diseases hence vaccine is not essential for such people. Again, no evidence is available that supports this myth. Similarly, this vaccine or any other FDA-approved vaccine can make you positive for viral detection test in PCR.Research on the COVID-19 vaccine will continue and will reveal more facts and dissolve many myths. It is advised to participate in getting yourself vaccinated to protect not only you but your family and community as well.

Practice variability with syringe labelling practices among anaesthesia residents.

Practice variability is associated with human error and adverse drug events. We sought to describe the practice variability that exists with drug labelling among acohort of anaesthesia residents in an academic medical centre. In acontrolled, lecture-style environment, residents were instructed to prepare asyringe of atracurium. Label location (longitudinal vs. circumferential), orientation (right hand vs. left hand), compliance, and legibility were assessed. Atotal of 32 syringes with 48 labels were analysed, of which 11 (34%) had asingle longitudinally placed label, 6 (19%) had asingle circumferential label, and 15 (47%) had both longitudinally and circumferentially placed labels. Of syringes with longitudinally placed labels, 17 (63%) were placed in the right-hand orientation, 9 (33%) in the left-hand orientation, and 1 (4%) had 2 labels placed in both orientations. Of the syringes with circumferentially placed labels, 17 (81%) were placed in the right-hand orientation and 4 (19%) in the left-hand orientation. Overall compliance with longitudinal and circumferential labels was 95.6% and 43.8%, respectively. Overall legibility with longitudinal and circumferential labels was 90.7% and 90.5%, respectively. Agreat deal of practice variability with syringe labelling among anaesthesia residents was observed, with significant non-compliance of circumferentially placed labels, which could play arole in increasing the risk of drug errors.

Risk of Patient Harm Related to Unnecessary Dilution of Ready-to-Administer Prefilled Syringes: A Literature Review.

Unnecessary dilution of ready-to-administer (RTA) syringes could increase the risk of patient harm attributed to errors related to incorrect dose, improper labeling, and the potential for microbial contamination. Although published guidelines endorse the use of commercially available RTA syringes, recent surveys indicate that best practices are not always implemented. The purpose of this article is to review the existing literature and to assess the incidence and nature of errors related to the unnecessary dilution of RTA intravenous (IV) push medications in the inpatient clinical setting. The PubMed database was searched to identify studies of errors related to the use of RTA syringes for IV push medications within the last 10 years. An additional search was conducted using other search engines to identify relevant articles in the grey literature. This literature review concludes that unnecessary dilution of IV push medication in RTA syringes is an unsafe practice that occurs routinely. This practice increases the risk of patient harm through errors related to incorrect dose, improper labeling of syringes, and the potential for microbial contamination of the product. Greater awareness of the risks associated with unnecessary dilution of RTA syringes is still needed to eliminate this unsafe IV push medication administration practice and to thereby further improve outcomes.

Tranexamic acid: Beware of anaesthetic misadventures

Tranexamic acid (TXA) is an antifibrinolytic agent that is commonly used in cardiac, gynecologic, and obstetric surgeries. Inadvertent intrathecal injection of the TXA may lead to serious side effects, including back pain, myoclonus, seizure, and ventricular fibrillation that can be attributed to similar appearance of ampoules, location of ampoules, and incorrect labeling of prefilled syringes and can be avoided by vigilance, correct labeling of syringes and ampoules, double checking medications prior to administration, and preventing manufacturing of vials of different drugs with similar appearance. Treatment of intrathecal injection of the TXA includes administration of the anticonvulsants, general anaesthetics, MgSO4, along with intensive haemodynamic monitoring, scalp electroencephalography monitoring guided burst suppression with thiopentone infusion and cerebrospinal fluid lavage.

Paediatric Anaesthetic Emergency Data Manual

A special challenge for healthcare practitioners is the emergency resuscitation of infants and children. James Armstrong and Hannah King have published the Paediatric Anaesthetic Emergency Data Manual as a guide specifically directed to the treatment of a life-threatening crisis. Its main audience are those involved in anesthetizing pediatric patients; however, the guide would be useful for anyone facing an in-hospital pediatric emergency.The guide is small, light, and composed of water-resistant paper; however, it is not small enough to fit into a pocket. It is sectioned by arrest, trauma, anesthetic, and medical flowcharts, most of which are emergency treatment algorithms, but some are management guidelines. Pain treatment, fluid management, and congenital heart diseases are examples. The information is helpful; however, to be useful it would need to be attached or located at the site of care. It appears that there is only a hard copy of the information available and no electronic version of the flowcharts that come with the book.Much of the information is available as a Pediatric Critical Events Checklist on the Society for Pediatric Anesthesia (SPA) website for printing and through a free iTunes app that is managed by the Children’s Hospital of Philadelphia. The guide, however, provides more detailed information than the SPA checklists in many sections, and the guide starts with age-appropriate charts from neonate to teen, which are especially useful for the infrequent pediatric practitioner.The guide succeeds as a single-source summary for a broad range of pediatric care. It is rare to find a compendium that tackles so many pediatric topics without becoming a textbook. The true utility of this text is that it is an excellent reference, so much so that one need not rely on memory during a life-threatening crisis or during the care of a child with one of the many identified congenital anomalies. The formulary at the end of the guide is also quite valuable.It is especially difficult to choose an organizational format for what is simply a list of medical conditions. The book’s division into four categories works; however, during a true time-critical emergency, a familiarity with the book would be required. There are a few informational boxes spread throughout the guide and attached to flowcharts, such as an informational box on the management of hyperkalemia. Because hyperkalemia may occur as a part of multiple separate emergencies, it might be better served to have a separate section devoted to it. I also had a little difficulty with the guide because the color scheme chosen for some of the backgrounds makes the text difficult to read, especially the dark blues and purples. The color coding seems to follow some of the safety labeling of anesthetic medication syringes, but serves more as a nuisance in this context.Overall, the content of this emergency manual is outstanding, and although the information can be found elsewhere, this book serves as a concise single source. It is definitely a practical, and likely a beneficial, tool for those who want a hard copy at hand in their operating, emergency, or intensive care suite. The authors were clearly thoughtful in including what would be the most effective information for their audience during a pediatric calamity.

Preventing medication errors in the perioperative setting: recommendations on drug syringe labels.

Preventing medication errors in the perioperative setting: recommendations on drug syringe labels.

Simulator evaluation of a prototype device to reduce medication errors in anaesthesia

We undertook a randomised control led trial to evaluate the effect of a prototype device which attaches to the intravenous drug administration port, and allows injection of intravenous drugs only after the user scans the barcode on the syringe label. This requires two steps: first, that the correct drug label is generated; and second, that the syringe-with-label is scanned before administration. Ten anaesthetists, who were unaware of the primary outcome being measured, administered general anaesthesia for two simulated standardised cases each without and with our prototype (control and intervention, respectively). The primary outcome measured was compliance with a safe drug administration procedure (defined as a two-step procedure where, step one is scanning a drug ampoule to print a label for a syringe and step two is scanning of the labelled syringe before administering it intravenously). A total of 182 intravenous drug administrations occurred in the study (91 in each group). We found that the use of our prototype increased safe drug administration behaviour in experienced anaesthetists; 33 (36.3% [95% CI 26-47%]) vs. 91 (100% [95% CI 96-100%]) in the control and intervention groups, respectively (p = 0.0001).

A System for Anesthesia Drug Administration Using Barcode Technology: The Codonics Safe Label System and Smart Anesthesia Manager.

Many anesthetic drug errors result from vial or syringe swaps. Scanning the barcodes on vials before drug preparation, creating syringe labels that include barcodes, and scanning the syringe label barcodes before drug administration may help to prevent errors. In contrast, making syringe labels by hand that comply with the recommendations of regulatory agencies and standards-setting bodies is tedious and time consuming. A computerized system that uses vial barcodes and generates barcoded syringe labels could address both safety issues and labeling recommendations. We measured compliance of syringe labels in multiple operating rooms (ORs) with the recommendations of regulatory agencies and standards-setting bodies before and after the introduction of the Codonics Safe Label System (SLS). The Codonics SLS was then combined with Smart Anesthesia Manager software to create an anesthesia barcode drug administration system, which allowed us to measure the rate of scanning syringe label barcodes at the time of drug administration in 2 cardiothoracic ORs before and after introducing a coffee card incentive. Twelve attending cardiothoracic anesthesiologists and the OR satellite pharmacy participated. The use of the Codonics SLS drug labeling system resulted in >75% compliant syringe labels (95% confidence interval, 75%-98%). All syringe labels made using the Codonics SLS system were compliant. The average rate of scanning barcodes on syringe labels using Smart Anesthesia Manager was 25% (730 of 2976) over 13 weeks but increased to 58% (956 of 1645) over 8 weeks after introduction of a simple (coffee card) incentive (P < 0.001). An anesthesia barcode drug administration system resulted in a moderate rate of scanning syringe label barcodes at the time of drug administration. Further, adaptation of the system will be required to achieve a higher utilization rate.

Experience with the use of the Codonics Safe Label System(™) to improve labelling compliance of anaesthesia drugs.

The Codonics Safe Labeling System(™) (http://www.codonics.com/Products/SLS/flash/) is a piece of equipment that is able to barcode scan medications, read aloud the medication and the concentration and print a label of the appropriate concentration in the appropriate colour code. We decided to test this system in our facility to identify risks, benefits and usability. Our project comprised a baseline survey (25 anaesthesia cases during which 212 syringes were prepared from 223 drugs), an observational study (47 cases with 330 syringes prepared) and a user acceptability survey. The baseline compliance with all labelling requirements was 58%. In the observational study the compliance using the Codonics system was 98.6% versus 63.8% with conventional labelling. In the user acceptability survey the majority agreed the Codonics machine was easy to use, more legible and adhered with better security than the conventional preprinted label. However, most were neutral when asked about the likelihood of flexibility and customisation and were dissatisfied with the increased workload. Our findings suggest that the Codonics labelling machine is user-friendly and it improved syringe labelling compliance in our study. However, staff need to be willing to follow proper labelling workflow rather than batch label during preparation. Future syringe labelling equipment developers need to concentrate on user interface issues to reduce human factor and workflow problems. Support logistics are also an important consideration prior to implementation of any new labelling system.

Refractory status epilepticus after accidental intrathecal injection of tranexamic acid

Tranexamic acid (TXA) is an antifibrinolytic agent that is commonly used in cardiac, gynecologic, and obstetric surgeries. Inadvertent intrathecal injection of the TXA may lead to serious side effects including myoclonus, seizure, and ventricular fibrillation. So far, the proconvulsive properties of TXA and its mechanism of action are poorly understood. Medical error leads to serious adverse effects that can be attributed to similar appearance of ampoules, location of ampoules, and incorrect labeling of prefilled syringes. We herein report a case of refractory status epilepticus after accidental intrathecal injection of TXA. The patient was treated with thiopentone infusions until achieving a burst suppression pattern on electroencephalogram along with other antiepileptic drugs. Subsequently, the patient recovered completely without any neurological deficit. To the best of our knowledge, this is the first case of refractory status epilepticus after inadvertent intrathecal injection of TXA. Such catastrophic complications can be avoided by vigilance, correct labeling of syringes and ampoules, double checking medications prior to administration, and preventing manufacturing of vials of different drugs with similar appearance.

MEDIKAMENTŲ IR ŠVIRKŠTŲ ŽYMĖJIMAS ANESTEZIOLOGIJOJE

According to research, error rate in anaesthesiology is approximately 1 in 1300 drug administrations. Therefore, measures were taken in order to reduce this number. Nowadays Food and Drug Administration (FDA) and European Union confirmed standards of drug labeling are used worldwide; these same standards are also used in Lithuanian University of Health Sciences Department of Anaesthesiology. Three standards that complement each other are: standard specification for labels for small-volume (100 ml or less) parenteral drug containers; standard practice to enhance identification of drug names on labels; anaesthetic and respiratory equipment – user-applied labels for syringes containing drugs used during anaesthesia – colour, design and performance standard.According to these recommendations, previously used labeling of ampoules, syringes or medication bags by writing with a black marker or using a manufacturer’s offered non-standard label was substituted with standardized drug labeling based on the 2008 International Organization for Standardization (ISO) standard. This colour-code labeling is based on practice, that every group of medications has a different label background colour. The antagonists’ labels are the same colour, but with white diagonal stripes.Because of the new system, there have been noticed great practical benefits in daily clinical work and significant improvement in quality indicators.

Three years after the launch of the Helsinki Declaration on patient safety in anaesthesiology

Three years after the launch of the Helsinki Declaration on patient safety in anaesthesiology

Manufacturers' obligations to colour‐code prefilled syringes correctly

I read with interest the letter from by Dr Torlot 1. The debate surrounding drug-label colour-coding in anaesthesia has been active for around 30 years, much of it taking place in this journal 2-4. In addition, an international colour-code standard for user-applied anaesthetic labels has now been adopted in the UK, the USA, Canada, Germany, Australia and New Zealand 5. It is therefore astonishing and rather alarming that a pharmaceutical manufacturer is able to bring to the market a prefilled syringe for suxamethonium that is colour-coded in a way dangerously inconsistent with the existing colour standard. The international colour-code standard has an additional safety feature specifically for potentially dangerous drugs like suxamethonium, namely the reversed lettering and background of the drug name as way of an alert to the user. Not only does the Aurum Pharmaceuticals prefilled syringe not have this reversed alert text, but the blue colour they have chosen for the syringe label is identical to that for opioids under the international colour standard. We know from a recent large-scale study of over 74 000 anaesthetics that syringe-swap errors between drug classes can be significantly reduced by using the new international colour standard because of the drug-class specific colour cues 6. Why would any manufacturer then use the same colour for two drugs from different pharmacological classes? I can imagine that the ‘legal’ response from a pharmaceutical company over such a matter might be to point out that it is the anaesthetist's responsibility to read the label (no matter how poorly labelled the drug) and that technically, the international colour-code standard is intended for ‘user-applied’ drug labels and therefore does not apply to the manufacture of a prefilled syringe which comes already labelled, hence allowing the manufacturer to make the label any colour it likes. The provision of a new prefilled syringe should be seen as an opportunity to increase patient safety by getting the details right, rather than bizarrely creating a new trap or latent system error that will in time inevitably lead to a new kind of error. Over ten years ago I pointed out that ampoule labelling standards are such that ampoule labels could carry colour-coding consistent with the international user-applied labelling standard 7. This would have significant ergonomic benefits for anyone drawing up drugs from colour-coded ampoules into similarly colour-coded syringes, and there is no reason why such consistency of colour-coding could not also apply to pre-filled syringes. In fact, in our hospital we have had consistently colour-coded prefilled syringes for over ten years 8.

Residual anaesthesia drugs in intravenous lines – a silent threat?

Residual anaesthesia drugs in intravenous lines – a silent threat?