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Medication Errors: Unlabeled Medications

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Medication Errors: Unlabeled Medications

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operating room

The solution cup on this surgical tray is not labeled

There are multiples ways medication errors occur: giving the wrong medication at the wrong time to the wrong patient by the wrong route or giving the wrong dose or for the wrong reason. There are special risks associated with liquids that are placed in syringes, basins or cups. These are true cases:

  • A man was severely burned when his physician mistakenly placed a detergent instead of vinegar on his genitals to remove warts.
  • A woman died after she was accidentally injected with a topical anesthetic solution instead of dye.
  • Ethyl alcohol was injected into a woman’s face instead of Lidocaine. Afterward she suffered from partial facial paralysis.

Medications may be present in doctors’ offices, same-day surgery units, clinics, labor and delivery room, cardiac catheterization areas, interventional radiology, endoscopy suites, operating rooms, or wherever procedures are performed. These errors occur because of miscommunication, inattention, fatigue, distraction, confusing manufacturers’ labels, making assumptions without validating them, being under pressure to complete a task and other factors.

Safe Practices for Labeling Medications
You are an attorney litigating a case involving a medication error caused by unlabeled medications. Here are some important safeguards that health care providers should follow to reduce the risk of this type of medication error.

  • Label solutions when they transfer them from the container to another container.
  • Recognizing the risks associated with unlabeled medications and solutions, manufacturers make preprinted labels available. Providers should place these on medications, cups, basins or syringes or other containers of chemicals and do this even if there is only one medication or solution involved. They should use blank labels when preprinted ones are unavailable. The label should contain the medication name, strength, quantity, diluent and volume (if not apparent from the container), expiration date when not used within 24 hours, and expiration time when expiration occurs within 24 hours.
  • Providers should complete labeling one solution or medication before preparing another medication.
  • Providers should use tall man lettering (putting parts of a medication name in all caps) when drug or solution names are similar. They should have another person concurrently verify all medications by looking at them and saying their names aloud.
  • When handing a solution or medication to a licensed professional who will be giving it, the provider should look at it and say what he or she is handing the person: “Doctor, I am handing you chlorhexidrine for cleaning the skin.”
  • The provider should keep all single and multidose medication or solution containers in the room until the procedure is over.
  • If the provider leaves before a procedure is finished, she should verify with her replacement the medications that are on the sterile field.
  • Providers should never assume they know what is in a basin, syringe, bowl or cup.

Med League supplies operating room nurses and surgeons to review cases involving perioperative medication error cases, as well as other types of experts. Contact us for help with your next case.

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