Labels: Friend or Foe

Ready-made labels are a time-saving device that clinicians have depended on for years. Whether used to denote when IV tubing will expire or direct when to throw out the green gelatin in the refrigerator, labels communicate information between caregivers. The requirements for the appropriate use of labels have been stepped up since the introduction of the National Patient Safety Goals (NPSGs), but hospitals are discovering that the requirements do not end there.

Labeling requirements outlined in NPSG.03.04.01 are precise, establishing a structured process for labeling items when they are added to the sterile field. Common violations of this standard include:

Medications drawn up in a syringe are either not labeled or include an incomplete label with only the name of the medication listed.
Medications and solutions used during minor or bedside procedures are not managed in a manner similar to the process in the OR.
Failing to keep used vials and containers until after the procedure, particularly with bedside procedures.

Since many organizations have improved compliance with this NPSG, surveyors have turned to other labeling issues that can be surveyed under MM.05.01.09. This extends the surveyor’s reach from the OR, where staff are ready for questions, to the bedside, where staff may not be prepared. The highest risks seem to include:

Medications (such as insulin), that are prepared in advance, perhaps following a “double check” and then placed, unlabeled, in the patient’s medication drawer until given.
Failing to label medications that are to be administered by someone else.
Incomplete information on antibiotic bags.

Many organizations use pre-made labels that contain only a portion of the information that clinicians should record as part of the process. Label manufacturers responded to the NPSG by producing labels, syringes, and other devices to make compliance easier. Having access to convenient labels is only one part of the solution for assuring compliance within the facility.

Complete labels, complete compliance.

Pre-printed labels provide some information, but there are occasions when labels must be created on the spot. To measure compliance, make sure your tracer teams check for the following:

Medication name, strength, and amount, if not already present on the container. This includes listing the name and concentration of the diluent, particularly for IV medications. This is important for labels in common use in the OR that only contain the name of the medication but require the clinician to write in the concentration.
Date prepared, applicable expiration times, and admixtures for any medications mixed outside the pharmacy (includes oxytocin mixed in the OR by anesthesiologists).
Ensure that solutions, including “saline” are labeled with the appropriate concentration. Be cautious of solutions that may be made in more than one concentration, particularly antibiotics.
When labels are used, include any information not already written on the container, and assure the label does not obstruct the container label.
Score noncompliant any syringes or containers found to be empty. No pre-labeling of syringes is permitted. All manufacturer pre-labeled syringes should be discarded.
Initials of the individual preparing the medication are also recommended.

Tracer teams should not limit tracers to the procedural suites (OR, ED, cath lab). Off-shift procedures done at the bedside are the source of common errors, as are procedures done in outpatient areas.

Next steps

Conduct a “treasure hunt” of all areas where procedures are performed, and look for any pre-labeled syringes, unlabeled pre-drawn syringes (yes, those syringes nurses are drawing out of a common IV bag), and labeling materials. Assure that sterile pens and labels are available to procedure personnel. Select each type of label available and post in a local area an example of compliant (and perhaps noncompliant) labels to illustrate expectations. Track and trend compliance both by location and circumstance to discover weaknesses in type of procedures or activities, and categories of caregivers. Assure that compliance data is shared with all applicable staff including the OR, cath lab, procedural areas, and applicable outpatient locations.