Unlabeled syringes are common safety threat
Injectable medications pose one of the highest risks for medication errors, and the risk often is related to identifying the proper drug and dosage in the syringe before administering it. Medication safety experts and risk managers often advise labeling the syringe when it is filled to avoid any confusion, but how often is that actually done? Not as much as you might think.
The truth is that busy nurses often forgo labeling syringes and trust they can remember what is in each syringe when injecting the drugs. And even when a syringe is labeled, it is not always done in a way that facilitates easy reading by all staff under less-than-ideal conditions. The Joint Commission has recognized this problem and made improved medication labeling one of its Patient Safety Goals.
Improve syringe labeling and you will reduce medication errors, says Douglas Dotan, MA, CQIA, president of CRG Medical in Houston, which offers patient safety quality management solutions to health care providers. He also is the outgoing chair of the health care division of the American Society for Quality in Milwaukee. But first you have to know what's really going on in your facility, Dotan says.
"One of the best things a risk manager could do is to go on rounds and see for [him or herself] what is happening when they prepare these syringes," he says. "And you have to remember that it's not just at the patient's bedside. It's in pharmacy dispensing, in the operating room, in the sterile field, all over the facility."
Proper labeling of a syringe should include the nurse's name, the date and time, the drug, and the dosage, Dotan says.
Error traced to lack of label
The hazards posed by unlabeled syringes were addressed recently by the Institution for Safe Medication Practices (ISMP) in Huntingdon Valley, PA. The ISMP calls unlabeled syringes a significant risk, offering this example of how the lack of a label can lead to a tragic mistake: A nurse injected a 15-year-old patient with an unlabeled syringe that was thought to contain Marcaine (bupivacaine) with epinephrine.1 The syringe actually contained 30 ml epinephrine 1:1,000. The patient's blood pressure increased rapidly after the injection, leading the staff to suspect malignant hyperthermia because the patient had a history of that problem. The medication error was not discovered until the patient developed ventricular tachycardia and pulmonary edema. The patient recovered.
An investigation revealed that the nurse who had prepared the syringe had intended to add it to several bags of normal saline, the ISMP reports. But she was called away and left the unlabeled syringe on a tray near the patient, where another nurse assumed it had been prepared for that patient.
Nurses say no consistency
A recent survey by the American Nurses Association (ANA) in Silver Spring, MD, suggests that such scenarios are surprisingly common in health care facilities. The survey of more than 1,000 nurses revealed that only 37% report they always label syringes, and 28% report that they never do.
ANA president Rebecca M. Patton, MSN, RN, CNOR, points out that a substantial majority of the nurses surveyed, 68%, said they believe medication errors can be reduced with more consistent syringe labeling. She agrees.
"Proper and consistent syringe labeling is one way to reduce risks associated with medication errors," Patton says.
Addressing the manner in which staff label syringes is a big part of the solution, Dotan says. Many well-meaning nurses try to label the syringes but find that doing so is just impractical, especially with the small syringes often used with children, because even the smallest stick-on labels or tape can obscure the measurement gradations. Labels also can fall off, leaving the nurse to guess what is in the syringe. Some labels also can make it more difficult to inject the drug, Dotan says.
In addition, some of the writing on syringe labels is so small often by necessity, because the syringe is so small that most people can't read the words.
"Once you have nurses over 40 or 50 years old, the experienced ones you trust so much; they can't even read those labels unless you provide them a magnifying glass," Dotan says. "Having a magnifier on every table or every cart can be a simple fix, a cheap and effective solution. But those are the kinds of problems that you have to uncover by going out on the floor and talking to people."
Patton notes that one possible solution is a write-on stripe manufactured on the syringe. One example is the InviroSTRIPE feature of syringes manufactured by Inviro Medical Devices in Lawrenceville, GA. The syringes come with an integral write-on stripe that allows for critical information to be recorded directly onto the syringe barrel. Several manufacturers provide pre-made labels that can be applied to syringes, and some more advanced drug dispensing systems will print a label that includes a bar code identifying the medication and tying it to the patient's records.
"Risk managers need to work with the quality improvement people and the nurses themselves to solve this problem. Be their friend more than their inspectors," Dotan says. "If you can't always use pre-filled syringes, make sure they use the commercially available labels and their units are restocked regularly. Consistency in use is a key to avoiding this type of error."
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Nurses report no consistent labeling Research from the American Nurses Association (ANA) in Silver Spring, MD, shows that even among those who label syringes, there is little consistency in how it is done, says President Rebecca M. Patton, MSN, RN, CNOR. And some of the methods are clearly not as efficient or reliable as others, she says. In a recent ANA survey of 1,000 nurses, 72% of nurses said they label syringes at least sometimes and reported using these different methods:
Patton notes that improving the labeling of syringes is not as easy as writing a policy and telling nurses to do it consistently. Challenges often arise when attempting to label a syringe, so practical solutions must be found that facilitate labeling under the real-world working conditions that nurses face, she says. For instance, some labels can cover the measurement gradations on the syringe barrel, a problem reported by 65% of the nurses surveyed, Patton says. Thirty-nine percent of the nurses reported that a label impairs their ability to accurately check the dosage when comparing it to the order creating another risk of medication error. |
Dotan recommends getting nurse input when looking for a labeling solution. Let the nurses tell you what really happens on the floor and why it may not be so easy to employ the procedures that seem like they should work.
"If you see someone not labeling a syringe, stop and ask them why. They'll probably tell you the truth," he says. "Ask the nurses what their concerns are and how they work around some of the limitations to the labeling systems. Those workarounds may lead to the more practical policy and procedure."
The risk manager should be sure to approach nurses in a helpful manner, rather than as an enforcer, Dotan says. Acknowledge up front that it is difficult for nurses to label syringes every time and ask how you can help make that more realistic.
"If you tell me to write on a 2 ml syringe for a neonatal, there's no way I can do that," he says. "So don't just send a memo saying they have to do it every time, because if it is not realistic, if they just can't do it, then you're setting them up for failure."
Reference
1. Institution for Safe Medication Practices. Errors with injectable medications: Unlabeled syringes are surprisingly common. Nurse Advise ERR 2008; 6(1):1.
Sources
For more information on labeling syringes, contact:
- Douglas Dotan, MA, CQIA, President, CRG Medical, Houston. Telephone: (713) 825-7900. Web site: www.crgmedical.com.
- Rebecca M. Patton, MSN, RN, CNOR, President, American Nurses Association, Silver Spring, MD. Telephone: (301) 628-5000. Web site: www.nursingworld.org.
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