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rity, likely because they had never experienced a drug error, and
assumed they knew what was in each drug vial. Making the wrong
assumption might result in only a few mistakes for every thousand
times they're made, but as this example shows, those few mistakes
can result in tragedy.
Any medication containers on the sterile field must be labeled —
period, end of story — and they must be labeled when medications
are drawn. Using pre-labeled containers to draw medications is a
dangerous practice. For example, it's common for nurses to use
pre-filled saline syringes to reconstitute antibiotics. But pre-filled
saline flush syringes look like syringes filled with only antibiotic.
Staff can get confused about which syringe contains what, and
could end up administering straight saline instead of the needed
antibiotics, or vice versa.
Clear and concise communication during drug handoffs is also
essential. A verbal and visual confirmation of what's being handed in
and out of the sterile field is always a good safety practice:
"Here's the atropine 1mg syringe."
"I'm taking the atropine 1mg syringe."
The person receiving medications should read what the passer is
saying by checking the label to confirm what they're being told is correct — she should never take the passer on her word.
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | M A R C H 2013
