Archive February 2017 XVIII, No. 2

Ideas That Work: Can You Spot These 7 Medication Label Errors?

NEOSTIGMINE NEOSTIGMINE The pre-printed label indicates 1 mg/mL, but the vial contains 0.5 mg/mL. This is a 100% differential for this potent medication, which is used with atropine to end the effects of neuromuscular-blocking drugs.
FLUMAZENIL FLUMAZENIL This vial of benzodiazepine reverser is 0.1 mg/mL, not 0.5 mg/mL as the label indicates. Theoretically, a patient in crisis requiring reversal would be underdosed should this potential error occur.
PHENYLEPHRINE PHENYLEPHRINE This adrenergic agonist is a high-alert medication, meaning the consequences of an error are more devastating. The product is 10 mg/mL, not 10 mg/10mL as the label indicates. In a crisis, we have a potential underdose.
ATROPINE ATROPINE Another dangerous error waiting to happen with a high-alert medication. The strength on the pre-printed syringe label doesn't match the manufacturer's vial label.
FENTANYL FENTANYL The fentanyl label, as provided by the printer and not reviewed by the facility, indicates 50 mg/mL. It's really 50 micrograms per mL, not milligrams.
EPHEDRINE EPHEDRINE This ampule of ephedrine is 50 mg/mL, but the label states 10 mg/mL. This is a seriously fertile opportunity for a significant med error due to this 5-fold difference.
EPHEDRINE BAG EPHEDRINE BAG The ephedrine bag simply does not reveal the strength of ephedrine within the IV bag.


Can You Spot These 7 Medication Label Errors?

When the pre-printed labels affixed to your medication storage bins and syringes don't match the contents of the drug that's stored inside, a serious medication error is just waiting to happen, says Sheldon S. Sones, RPh, FASCP, a pharmacy consultant from Newington, Conn. To illustrate the risk, Mr. Sones took these 7 unstaged photographs of medication labels he observed in various anesthesia carts. "Drug shortages that force you to use substitute products that don't correlate to your existing labels only increase the chances of a medication error," says Mr. Sones.

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