1 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • F E B R U A R Y 2 0 1 7
W
hen the pre-printed labels affixed to your medication stor-
age bins and syringes don't match the contents of the drug
that's stored inside, a serious medication error is just wait-
Can You Spot These 7 Medication Label Errors?
• EPHEDRINE BAG The ephedrine bag simply does not reveal the strength of ephedrine
within the IV bag.
• EPHEDRINE This ampule of ephedrine is 50 mg/mL, but the label states 10 mg/mL.
This is a seriously fertile opportunity for a significant med error due to this 5-fold difference.
• FENTANYL The fentanyl label, as provided by the printer and not reviewed by the
facility, indicates 50 mg/mL. It's really 50 micrograms per mL, not milligrams.
• ATROPINE Another dangerous error waiting to happen with a high-alert medication.
The strength on the pre-printed syringe label doesn't match the manufacturer's vial label.
• PHENYLEPHRINE This adrenergic agonist is a high-alert
medication, meaning the consequences of an error are more
devastating. The product is 10 mg/mL, not 10 mg/10mL as
the label indicates. In a crisis, we have a potential underdose.
• FLUMAZENIL This vial of benzodiazepine reverser is 0.1
mg/mL, not 0.5 mg/mL as the label indicates. Theoretically,
a patient in crisis requiring reversal would be underdosed
should this potential error occur.
• NEOSTIGMINE The pre-printed label indicates 1 mg/mL,
but the vial contains 0.5 mg/mL. This is a 100% differential
for this potent medication, which is used with atropine to
end the effects of neuromuscular-blocking drugs.