labels remains legible even after being hit with fluids that often splash
onto the sterile field. The same can't be said for handwritten labels,
which can smear when wet, but which are still needed to identify sel-
dom-used agents. When filling out handwritten labels, be sure to note
the medication's name, strength and dose.
Color-coded labels provide staff with a quick and easy way to identi-
fy the contents of a syringe or container, but that benefit is also a
potential drawback. We've eliminated the use of color-coded labels,
because we found that staff members were relying on the color of
labels when retrieving needed medications instead of rereading and
rechecking the information on conventional labels.
6. Encourage sharing. Reporting adverse events is an effective way to
prevent similar mistakes from occurring. Make sure staff members
understand that their reporting of errors and near misses will not be
met with punishment (unless, of course, their actions were a careless
and intentional disregard for patient safety).
The tech who accidentally filled the syringe with local anesthetic felt
comfortable speaking up, which can be a difficult thing to do, because she
knew we'd support her willingness to own the error. She showed courage
in putting patient safety above her own pride, but she also knew our
response would be a non-punitive investigation to protect future patients
from potential harm.
It's also a good idea to share the lessons learned from near misses
and mistakes at daily morning huddles. There's no better way to raise
awareness than to have staff members share their insights from a real-
life event — when the details are still fresh in their minds.
OSM
A P R I L 2 0 1 7 • O U T PA T I E N TS U R G E R Y. N E T • 1 3 3
Ms. Dutton (catherine.dutton @baystatehealth.org) is the clinical nurse
educator of perioperative services and Ms. Betti (diane.betti@baystate-
health.org) is the director of inpatient surgery, pre-op, PACU and sterile
processing at Baystate Health in Springfield, Mass.
