Archive July 2018 XIX, No. 7


Can You Spot the Drug Safety Hazard?

Sheldon Sones, RPh, FASCP



It's no secret that poor documentation, dangerous abbreviations and unlabeled syringes can lead to harmful medication errors or adverse drug events. What's surprising is how often they occur in surgery. See if your nursing and anesthesia providers can spot the medication error in each of these 6 real-life photos. Let's start with a common drug charting infraction: trailing zeros and naked decimal points.

  • No trailing zeros. Is this 1 mg or 10 mg of midazolam? One of the most dangerous and frequent error-prone abbreviations is the trailing zero after a decimal point — 1.0 mg in this example. The correct entry would simply be "1 mg." If you don't see the decimal point, 1.0 could be administered as 1 mg or 10 mg — admittedly a high dose, but a ten-fold dosing option is feasible with midazolam. Regardless, never add a trailing zero.

Similarly, shield your eyes from naked decimal points (one without a leading zero). Never write a dose as .5 mg, for example. For clarity, always apply a lead zero before a decimal point when the dose is less than a whole unit — 0.5 mg in this example. If you don't see the decimal point, you can easily interpret .5 mg as 5 mg.

  • Is that all there is? These labels are missing so much required information. The expectations for the labeling of syringes call for more explicit detail: drug name, strength, date, time and the preparer's initials. A sticker that says "Vanco" does not a label make.
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