Unraveling the unlabeled containers issue
From the June
Problem: We have received several reports about incidents
where, because containers were not labeled, patients received
incorrect products. In the first incident, a 37-year-old
male patient's genitals were severely burned when his university
hospital-based physician mistakenly applied T.B.Q.® (a
cationic germicidal detergent with a pH of 13), instead of
vinegar. The patient was supposed to have a genital
wart evaluated and removed, and vinegar is commonly used to
bleach the wart to make it easier to see. However, the
physician retrieved an unlabeled bottle from the cabinet,
assumed it was vinegar, and applied the product with cotton.
In the second incident, hydrogen peroxide was injected instead
of lidocaine for local anesthesia. During surgery, hydrogen
peroxide was drawn into a syringe from an unlabeled basin
instead of lidocaine, which was in an unlabeled cup.
The patient suffered no adverse reaction. Last year,
a patient was accidentally injected with lidocaine 2% instead
of contrast media [Omnipaque® (iohexol)] during angiography.
The patient suffered a grand mal seizure but recovered.
Both the lidocaine and the contrast media had been placed
in the sterile field in unlabeled syringes. We are also
aware of another incident in which contrast media from an
unlabeled aluminum basin was infiltrated around the injection
site instead of lidocaine for local anesthesia just prior
to angiography. The lidocaine was also in an unlabeled basin.
Local tissue damage resulted.
Safe Practice Recommendation: Label everything.
No ifs, ands, or buts. Label everything everywhere at
all times, whenever it will leave your hand, even if the medication
is to be given immediately. It only takes a second for
the wrong medication or chemical to be given to a patient.
As we wrote in the December 4, 1996, issue of the ISMP Medication Safety Alert!, a 7-year-old boy died as a result of receiving
an injection of epinephrine instead of lidocaine during surgery
because, as is typical of many surgical fields, the basins
and cups were not properly labeled.
When you cook dinner at home, do you use an ingredient that
does not have a label? Would you just guess at what
it was? Would you assume that, because it was in a certain
position on the shelf, it was what you wanted? Amazingly,
although you don't usually do this at home, it happens again
and again in surgical fields, hospitals, physicians' offices,
and pharmacies every day. Patient harm, or even death, is
too often the result.