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Preserve medication safety in the OR

Single vs. multiple-dose local anesthetic vials

From the April 9, 1997 issue

Problem:Multiple-dose vials of local anesthetics that contain preservatives carry labeling that states that they are not for epidural use, caudal infiltration, or spinal anesthesia. Depending on the type of preservative, possible neurological complications associated with spinal use include transient leg pain or weakness or even permanent paraplegia and death.1 Despite warnings on the labels, mix-ups sometimes do occur between multiple dose vials and unpreserved products packaged in single-dose vials. Not all hospital support staff and professional personnel are aware of the differences between products. Look-alike packaging, as well as obscure warnings on drug containers, can contribute to problems

We recently received a report of an error due to a mix-up between look-alike vials of 30 mL preservative-free bupivacaine 0.25% with epinephrine 1:200,000 and 50 mL bupivacaine 0.25% with epinephrine 1:200,000 preserved with methylparaben. The warning statement on the multiple-dose vial was in small print, integrated with other text on the label. Since it did not stand out, it went unseen. Nothing about the labeling helped to differentiate the packaging. OR personnel ordered the wrong item from the pharmacy, however the mix-up was discovered before any patient received the wrong drug

In another case, the box for a 20 mL single-dose Carbocaine®(mepivacaine) 2% vial was nearly mixed-up with a box containing a 50 mL vial of preserved Carbocaine 2%. The boxes were practically identical in size, color and labeling except for the warning against spinal use on the multiple-dose vial package.

Image of Carbocaine
Picture of Carbocaine® vials, sigle and multiple-dose packaging.
Note the differences and similarities.

Safe Practice Recommendation:Multiple-dose local anesthetic products may not be necessary in the operating room. Anesthesiologists often use only preservative-free products, and surgeons and others can use these as well, simply discarding unused product after each procedure. A 1990 study of potential spread of iatrogenic infections through multiple-dose vials showed that, in simulated use, up to 24% of personnel contaminated multiple dose vials by using a single syringe to inject an infected patient and then enter a vial to draw up additional medication.2 This is another good reason to avoid multiple-dose vials

Consider if potential medication errors can be avoided entirely by eliminating or restricting use of preserved local anesthetic products in the OR and perhaps elsewhere. If they must be used, make sure that support staff and others are aware of the risks and differences between products. Develop a check system for products sent from the pharmacy in response to requisitions. Some manufacturers use shaded backgrounds and modified nomenclature to help differentiate these products. For example, Astra's preservative-free products have a brown, shaded background over a large portion of the label and use the suffix "MPF" (e.g., Xylocaine-MPF®) to indicate that it is methylparaben (preservative)-free.

Obviously, there is no substitute for reading the label, but education and modification of packaging can go a long way to help practitioners avoid errors. [D and N (anesthesia, surgery), P, T].

References: 1. Gelman CR, Rumack BH, Hess AJ. DRUGDEX® System. MICROMEDEX, Inc., Englewood, CO. Exp. May 31, 1997. 2. Plott RT, Wagner RF, Tyring SK. Iatrogenic contamination of multidose vials in simulated use. Arch Dermatol. 1990;126:1441-44

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