Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Dangers Associated with Unlabeled Basins, Bowls, and Cups B eginning in 1997, the Institute for Safe Medica- tion Practices (ISMP) reported on cases in which patients have inadvertently received the incorrect dure, an anesthesiologist accidentally injected the glutaraldehyde intrathecally, believing it was the pa- tient’s spinal fluid.2 product due to mistakes involving unlabeled medica- tions and solutions. Reports submitted to PA-PSRS Recent findings from the 2004 ISMP Medication reveal that unlabeled bowls, basins, and cups con- Safety Self Assessment® for hospitals, gathered from tinue to present a problem. more than 1,600 hospitals across the country, show that less than half (41%) of the hospitals always label One report described an occurrence in an operating containers (including syringes, basins, or other ves- room (OR) where Monsel’s solution (20% ferric sub- sels used to store drugs) on the sterile field, even sulfate) and Lugol’s solution (potassium iodide) were when just one product or solution is present. Eighteen both on the surgical field. The surgeon, wanting to percent do not label medications and solutions on the use the Lugol’s solution, removed the Monsel’s bowl sterile field at all, and another 41% apply labels incon- off the field without asking the scrub nurse to identify sistently. Although this represents an improvement the solution. No further information was contained in from the 2000 findings (25% reported full labeling; the report. In another report highlighting what could 24% reported no labeling), surprisingly, this rather have been a dangerous situation, three unlabeled basic safety measure is not widely implemented in basins that contained water, saline, and renografin most hospitals.3 solutions were found on a sterile back table in the OR. While you may not have experienced a Serious Event involving unlabeled medications and solutions, it is Several reports outside of PA-PSRS that gained na- important to develop and implement policies and pro- tional attention illustrate the potential hazards of this cedures for the safe labeling of these items, which are practice. In one case, a 37-year old male patient’s often used in sterile settings. These settings include genitals were severely burned when his physician operating rooms, ambulatory surgery units, labor and mistakenly applied TBQ (a cationic germicidal deter- delivery rooms, physician’s offices, cardiac catheteri- gent with a pH of 13) instead of vinegar for a wart zation suites, endoscopy suites, radiology depart- removal. In another case, a patient was accidentally ments, and other areas where operative and invasive injected with hydrogen peroxide instead of lidocaine procedures are performed. Consider the following for local anesthesia. During the surgical procedure measures, most of which are mentioned in the Asso- hydrogen peroxide was drawn into a syringe from an ciation of PeriOperative Registered Nurses (AORN) unlabeled basin instead of the intended lidocaine, Guidance Statement: Safe Medication Practices in which was also in an unlabeled cup. Even in the radi- the Perioperative Practice Settings.4 ology department, unlabeled products can lead to tragic outcomes. For example, a patient was acciden- Examples of safe practices to consider include: tally injected with lidocaine 2% instead of contrast media [Omnipaque (iohexol)] during angiography. • Making labeling easy by purchasing sterile mark- The patient suffered a grand mal seizure but recov- ers, blank labels, and preprinted labels prepared ered.1 A report from Hospital Pharmacy in 1989 described This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 1—March 2005. The Advisory is a publication of the Pennsylvania Patient the case of a patient who died during a surgical pro- Safety Authority, produced by ECRI & ISMP under contract to the Authority as cedure to remove a cancerous eye. In this case, an part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). unlabeled specimen cup was filled with glutaralde- hyde to preserve the patient’s enucleated eye, but Copyright 2005 by the Patient Safety Authority. This publication may be re- printed and distributed without restriction, provided it is printed or distributed in was mistaken as spinal fluid. The fluid had been re- its entirety and without alteration. Individual articles may be reprinted in their moved to reduce pressure because the malignancy entirety and without alteration provided the source is clearly attributed. had spread to the brain. The spinal fluid was in an identical unlabeled cup. Near the end of the proce- To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Dangers Associated with Unlabeled Basins, Bowls, and Cups (Continued) by the facility or commercially available (e.g., • When passing a medication to the licensed pro- Healthcare Logistics) that can be opened onto the fessional performing the procedure, visually and sterile field during all procedures. To minimize verbally verifying the medication, strength, and staff time, prepare surgical packs in advance with dose by reading the medication label aloud. sterile markers, blank labels, and preprinted la- bels for all anticipated medications and solutions • Keeping all original medication/solution contain- that will be needed for the case. ers the room for reference until the procedure is concluded. • Using labels on all medications, syringes, medi- cine cups basins, or other containers of solutions • At shift change or relief for breaks, having enter- as well as chemicals, reagents on and off the ing and exiting personnel concurrently note and sterile field, even if there is only one medication verify all medications and their labels on the ster- or solution involved. ile field. • If drug or solution names are similar, using tall • Not making assumptions about what is in an unla- man lettering on the labels to differentiate them beled basin, bowl, cup or syringe. (e.g., HYDROmorphone) or highlight/circle the distinguishing information on the label. • Discarding any unlabeled medication/solution found and considering the occurrence as a near • When possible, purchasing skin antiseptic prod- miss. ucts in prepackaged swabs or sponges to clearly differentiate them from medications or other solu- • Performing regular safety rounds in areas that tions to eliminate the risk of accidental injection. routinely have basins, bowls, cups, etc., to ob- serve labeling procedures, promote consistency, • Individually verifying each medication and com- and inquire about barriers to change. pleting its preparation for administration, delivery to the sterile field, and labeling on the field before Notes another medication is prepared. 1. ISMP. Medication Safety Alert! 18 June 1997. (2), 12. 2. Cohen MR. Medication Error Reports. Hospital Phar- • Verifying with the physician any medication on the macy.1989;24(7).549. physician’s preference list before delivery to the 3. ISMP. Medication Safety Alert! 12 December 2004. (9), 24. sterile field, labeling, and/or administration. 4. Association of periOperative Registered Nurses (AORN). AORN Guidance Statement: Safe Medication Practices in Perioperative • Having the scrub person and circulating nurse Practice Settings [online]. 2004. [Cited 22 Feb 2005.] Available on Internet: http://www.aorn.org/about/positions/pdf/7f-safemeds- concurrently verify all medications/solutions visu- 2004.pdf ally and verbally by reading the product name, strength, and dosage from the labels. If there is no scrub person, the circulating nurse could verify the medication/solution with the licensed profes- sional performing the procedure. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2005 Pennsylvania Patient Safety Authority Page 3