Standardized colour coding for syringe drug labels: a National Survey

Abstract

A standardised colour code for user-applied syringe labels for anaesthetic drugs exists in the USA, Australia, New Zealand and Canada. In the UK, there is none. Consequently, an assortment of colour codes for syringe labels is available in the UK. We conducted a postal survey of the 285 College Tutors of the Royal College of Anaesthetists to establish their local syringe drug labelling system and their views on a national, standardised colour code. We found that that 96% of departments currently use coloured syringe drug labels. Of these, 98% use the 'Medilabel' scheme. The College Tutors felt that a standardised colour code for labels is required (94%), that the Association of Anaesthetists or the Royal College of Anaesthetists should be involved in the choice of scheme (76%) and that the scheme chosen should be international (65%). There was a majority feeling that the opinions expressed were representative of other members of the College Tutors' departments. We conclude that a national standard for drug labels is required and that a choice will have to be made between the 'international' scheme and the currently dominant Medilabel scheme.

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

“…In this review, ampoule identification errors were more common than syringe swaps, which contrasts with Currie et al's [9] original study and may reflect more widespread use of improved labelling systems with colour coding to reduce the number of syringe swaps. There has been ongoing debate on the safety of syringe labelling and its place in preventing errors [24][25][26][27][28][29][30]. Although Fasting et al [27] were unable to show a statistically significant decrease in the frequency of drug error with colour labelling, their methodology and statistical analysis have been questioned, with Orser et al [12] suggesting that if these data were correctly analysed the results would support the use of a colour coding system.…”

“…The inconsistency among drug manufacturers in drug containers and labelling remains a well known risk and has been a long-standing point of controversy [11,36]. Although some have advocated that all ampoules should be identical to ensure the label is read carefully [25], it is recognised that humans tend to see what they expect to see, and words are not usually recognised by what is written but by their shape (the Poggenorf effect) [28,37]. The use of pre-packaged syringes may circumvent the ampoule problem.…”

Evidence‐based strategies for preventing drug administration errors during anaesthesia

“…Surveys of opinion of specified 'experts' [53,57]; reports of expert committees [55]; book chapters [56]; narrative reviews [52]; editorials, or articles expressing the viewpoint of one or more acknowledged experts in the field [62] …”

Anaesthesia after cleft palate repair

“…Some trials of BIS monitoring in the setting of electroconvulsive therapy suggest that it may record seizure activity. These trials were focussed on the level of anaesthesia achieved on induction and on awakening from ECT [2][3][4]. Others have reported its use in the intensive care setting to monitor the sedation of neurosurgery patients [5] and also in the setting of paediatric intensive care [6].…”

“…While it is not possible to identify definitively the cause of the discrepancy in readings without closer direct examination, the suggestions made by the authors for determining the cause for the discrepancy are sound. In addition, we suggest that clinicians refer to the directions for use for both the reusable cable [2] and the disposable transducer kit [3] to obtain further information.…”