The Art of Syringe Labeling in the ED

The ‘look-alike, sound-alike’ nature of many drug appearances and names is problematic. In high-stress environments such as the Emergency Department (ED), potential disasters can arise if “drug swap” or other medication errors occur. Drug swap is the accidental injection of the wrong drug.¹ The anesthesiology literature contains several published reports presenting various ideas on how to properly label syringes used in the operating room to reduce medication errors. Techniques include color-coding the labels,² labeling of the plunger,³ double-labeling,^4,5 and specific placement of the labels on the syringe.⁶

Because labeling is such an important medication safety topic, Dr. Nicholas Chrimes (@NicholasChrimes) and others have started petitions in Australia, New Zealand, and the United Kingdom aimed to improve mandatory national standards for manufacturer-applied drug packaging. A Twitter account (@EZDrugID) and hashtag (#EZDrugID) have been created to raise awareness of the topic.

With regard to user-applied anesthetic labels, international standards do exist for color-coding these syringe labels. The standards have been adopted in the UK, the USA, Canada, Germany, Australia, and New Zealand (though they are not universally practiced).⁷ An abbreviated example is shown here from.²

Syringe Labeling in the ED

Many EDs (like mine) don’t have the luxury of stocking color-coded labels for preparing drugs in emergent situations. When preparing syringes at the bedside, the literature supports two commonalities about what information is absolutely needed on the label: drug name and concentration.²

1. Drug Name: This one is obvious, though generic names should be used preferentially rather than brand names.
2. Concentration: It’s easy to simply write a dose on the label. Using ketamine as an example, let’s imagine that the label says Ketamine 100 mg. If 50 mg of the drug were administered and the syringe is placed back down, the next person to grab that syringe might still assume there is 100 mg left. However, if the concentration is written on the label, there will never be a question as to how much drug remains in the syringe.

Here’s how I prepare meds at the bedside using some generic yellow labels I have in my ED.

Other tips to potentially reduce errors (not all-inclusive):

• Don’t place the syringe down (as in my example above).
• Use the repeat back method when handing the syringe off to someone else.
• Discard the syringe when done (but save the bottle – see next tip).
• Save the manufacturer bottle – in case there is an adverse event, having the bottle available makes it easier to track back the error to the user/drug or lot number for further investigation
• If more than one medication is being drawn up, label each immediately after preparation (and not at the end of drawing up multiple medications).
• Make sure the graduations on the syringe remain visible after the label is applied.
• If able, specify route of administration on the label as some medications can be given via multiple routes (IV, IO, IM, or SQ). Syringes are also often used to give intranasal or oral medications, especially in pediatrics.
• It should go without saying, but… make sure the writing on the label is legible. In fact, preprinted labels are an even better option. Dr. Scott Weingart (@emcrit) has graciously shared his label sheet template (right click and choose save-as) which can be printed in large quantities. Tall Man lettering is recommended.

Depending on institutional policies, there may be other information needed on the label such as preparation time and date. However, drug name and concentration are crucial. Keep in mind that color-coded labels have not been proven to eliminate errors completely. This is in part because the colors generally represent a drug category and not an individual agent.^8,9 There may be a false sense of security that the bedside clinician has chosen the correct medication simply based on color. In a recent study using pediatric resuscitation simulation models, innovative color-coded syringes decreased the critical error rate to zero.¹⁰

The Joint Commission National Patient Safety Goals include a specific goal (NPSG 03.04.01) stating “Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.” This goal is meant to improve the safety of using medications.

For further discussion, I had the privilege of talking about syringe labeling and other ED medication errors with Dr. Weingart on his EMCrit podcast 103.

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