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The Impact of Labeling on Reducing Medication Errors
Medical Devices
Although the United States touts some of the best healthcare in the world, medication errors continue to be a problem in the industry. Because many times errors go unreported, it is impossible to isolate just one cause of the high medication error rate, but many approaches to medication error prevention have come to light. One of the approaches to medication error prevention and increasing patient safety is to require appropriate medication and syringe labeling; ensuring that the right drug in the right dose, with the right route of administration is given to the right patient at the right time.
Why Do Medication Errors Happen?
As defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), medication errors are "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
It is estimated that the number of lives lost to mistakes that could have been avoided with medication error prevention techniques alone represents approximately 7,000 deaths annually, and medication errors occur in just about one out of every five doses given in hospitals (1). These are voluntary reports and, as stated previously, many errors may go unreported, so the number of medication errors that actually occur is thought to be much higher.
There is no standard medication error, and, because the practice of medicine is so complex, there are many opportunities for mistakes to occur at any step between diagnosis, transcription, prescription and administration of the medicine.
Some of the most common causes of medication errors include:
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Miscommunication of drug orders; which can involve messy handwriting, incorrect abbreviations, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units;
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Performance and knowledge deficits due to improper training or education;
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Unavailable drug information (such as lack of up-to-date warnings);
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Lack of appropriate labeling as a drug is prepared and repackaged into smaller units.
Although many would like to put the blame on a particular individual for medication errors, improving patient safety through medication error prevention requires a systems-based approach in order to modify the conditions that contribute to errors.
Labeling as an Approach to Medication Error Prevention
Considering that medication errors in hospitals occur most frequently at the prescribing and administration stages (2), there has been a big push by patient safety groups to ensure accurate medication and syringe labeling.
In 2004, as part of a wide-ranging effort to improve patient safety, the FDA passed a medication error prevention rule requiring bar codes on the labels of thousands of human drugs and biological products. The measure seeks to protect patients from preventable medication errors by helping ensure that health professionals give patients the right drugs at the appropriate dosages. The rule was passed with the intent of improved medication error prevention in hospitals and other health care settings by allowing healthcare professionals to use bar code scanning equipment to ensure that the drug is administered accurately. The rule also requires the use of machine-readable information on blood and blood component container labels to help reduce medication errors (3).
In addition, the NCC MERP, an organization of pharmacy and healthcare professional groups, the U.S. Food and Drug Administration, the U.S. Pharmacopoeia and consumer organizations, among others, have developed numerous recommendations for medication error prevention. These recommendations, addressed to pharmaceutical manufacturers, packagers and re-packagers, hospitals and hospital pharmacies, outpatient pharmacies, physicians and other healthcare personnel, are expected to lead to the safer use of drugs in all patient settings. Among NCC MERP's recommendations:
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Print warnings only on caps and ferrules of injectables;
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Make intravenous drug names visible on both sides of the container;
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Print drug names in type that is at least as large as company names and logos.
Recently, The Joint Commission stepped up to provide administrators with another tool to help with medication error prevention. As part of the Commission's 2007-2008 National Patient Safety Goals, all medications, medication containers (syringes, medicine cups, basins) and other solutions, both on and off the sterile medical field, must be labeled (4) (data included on the label is at the institution's discretion). This is a significant goal in the area of medication error prevention since it encompasses not only operating rooms, but any place within a hospital where procedures are performed; i.e. patient's bedside, examination room, etc. Currently, hospitals use a variety of methods to label containers and syringes containing medications including stick-on labels, adhesive tape, commercial labels with gummed backs, steri-strips or most recently, a syringe with an integral write-on white stripe.
American Nursing Association (ANA), 2007 Study of Injectable Medication Errors
In June, 2007, the ANA released a survey on the subject of injectable medication errors. Not surprisingly, the vast majority of nurses worry about medication errors, with the busy work environment, poor or illegible handwriting and missed or mistaken physician's order cited as the top three reasons for those errors. Referring specifically to syringes, the survey revealed significant difficulties associated with syringes and welcomed the addition of a write-on stripe that would allow critical information to be recorded directly onto the syringe barrel. For more information and copies of the survey, please visit www.nursingworld.org.
Conclusion
There are a number of factors at each step of the patient care process that contribute to the high rate of medication errors in the healthcare industry. Special focus should be given to the prescription and administration phases of patient care due to the large number of errors tracked back to those stages of treatment. Today, patient safety and consumer groups continue to search for new means to decrease the high error rate, ensuring appropriate medication and syringe labeling will remain an important issue in the mission for medication error prevention.
Sources
1. Tipton DJ, Giannetti VJ, Kristofi k JM. Managing the aftermath of medication errors: managed care's role. J Am Pharm Assoc. 2003; 43:622-9.
2. 2007 National Academy of Science. Preventing Medication Errors: Quality Chasm Series (www.nap.edu/catalog/11623.html)
3. 2003 U.S. Food & Drug Administration, Protecting and Advancing Consumer Health and Safety (www.fda.gov/oc/whitepapers/consumers.html)
4. 2008 National Safety Patient Goals, Hospital Program, Goal 3D (www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm)
