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SAFETY
Theresa Criscitelli, MS, RN, CNOR
How to Avoid Medication Labeling Errors
Ensure that your patients don't receive incorrect medications.
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nlabeled medications and solutions on the sterile field can have negative, even deadly, outcomes. Take this tragic incident, for example.
An anesthesiologist accidentally gave a patient who'd just had his
cancerous eye enucleated an intrathecal injection of glutaraldehyde from an
unlabeled specimen cup. The anesthesiologist thought he was giving the
patient the spinal fluid he had aspirated before surgery to decrease the
patient's cerebral pressure, as the malignancy had spread to the brain. He had
placed the spinal fluid in a small vial marked "SF" on the sterile field for reinjection at the end of the surgery.
How did this mixup occur? As detailed in the July 1989 "Medication
Error Reports" in Hospital Pharmacy, when an ophthalmology resident
entered the room to retrieve the eye for biopsy, the specimen wasn't yet
ready to be taken, so he left the specimen storage container on the sterile
field and left the OR. The unlabeled container, which was identical to the
cup holding the spinal fluid, contained glutaraldehyde to preserve the eye.
Are your patients protected?
Could something like that occur at your facility? Unless you've implemented a medication labeling process to prevent untoward outcomes and minimize errors, it could. In 2006, the Joint Commission focused attention on
medication labeling and issued a National Patient Safety Goal, which directed healthcare providers to immediately label all medications, medication
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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 | J A N U A R Y 2013
