What could go wrong?

[deleted162650]

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[nimbus]

You are lucky yours are not covered in RFID tags, inventory control stickers and warning stickers. Our vials require some unwrapping to reveal their true identity.

 

[ZzzPlz]

Ours come in little plastic single bottle packaging. Only med we have like that. I like it that way

 

[ZzzPlz]

And I just got annoyed last week because our new zofran and decadron vials looks so similar. This puts things in perspective

 

[fakin' the funk]

Wow.

At least it's 1ml vs 2ml. But... Yikes.

 

[Ezekiel2517]

To make it worse, there's been accounts at multiple hospitals of pharmacies mistakenly stocking their drug trays with phenylephrine vials in the spots allocated/labeled for zofran.

 

[Ronin786]

Ours in residency were like that. Definitely know of someone who pushed the phenylephrine. Thank God the patient was otherwise healthy.

Only benefit is phenylephrine is short-acting.

 

[DrAmir0078]

It happened too here between Ketamine and Esmeron (same yellow cap)

 

[Psai]

It's not like there are a million different colors to choose from for the drugs that we use routinely.

 

[caligas]

I think the color coding of drugs may actually be a safety problem more than a solution. It puts people into the habit of not reading the label.

 

[BB80]

It's exactly like that at my hospital too. Definitely grabbed the wrong vial before, but thankfully always double checked.

When I was in residency, a pushy internal medicine resident came to PACU postop to see a patient and told the nurse to give 50mg phenylepherine ivp. The PACU nurse knew enough to know that was wrong, asked if she meant mcg, and said she wouldn't give it without a physical computer order (med resident was trying to verbal). So the resident actually put the order in and the nurse draws up 5 vials and gives it push. Can't remember for sure but I think the systolic got to 300... Thankfully not my patient, and pt did ok

 

[deleted875186]

To make it worse, there's been accounts at multiple hospitals of pharmacies mistakenly stocking their drug trays with phenylephrine vials in the spots allocated/labeled for zofran.

This sounds very dangerous .... I’ve also found incorrect vials of drugs in trays or stocked in the Pixis due to similar packaging. There’s no getting around double checking the vial as you draw it up.

 

[sevoflurane]

Always turn the vial and look at the label AS you are drawing up your meds. Human error will always be a subject of concern, but a proper process for drawing up meds/checking meds can help avoid medication errors.

 

[Mman]

what I find frustrating is the constant med shortages that lead to hospitals getting drugs from new suppliers periodically and they will have completely different labels or vials. I mean you know what the drug vial looks like for 10 years and then one day you don't even get a notice that it's totally different and you end up in a hurry with a crashing patient and trying not to make a mistake.

I always try to force myself to read the words on the label as it's being drawn up to avoid making that error. It is unfortunately easy to screw up if in a hurry, though.

 

[psychbender]

Check the label three times. Once for you, once for the patient, and once for the lawyer.

These are becoming more and more common, as hospital pharmacies keep switching manufacturers due to rolling shortages and slightly cheaper sources

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[shepardsun]

We have the same blue capped zofran vials. They happen to lay in the tray immediately adjacent to the 200 mcg vial of dexmedetomidine, whose cap color is, you can probably guess, the exact same shade of blue.

We recently got the "safe label system" printers that sit on the pyxis. You can scan the barcode of the drug and it prints out a syringe label with name, concentration, time drawn up, etc. I like it because I'm lazy and my handwriting is terrible, but it has a nice secondary benefit of announcing out loud as it's printing the label what the drug name and concentration is. One more check in addition to my own vigilance.

 

[nimbus]

It's exactly like that at my hospital too. Definitely grabbed the wrong vial before, but thankfully always double checked.

When I was in residency, a pushy internal medicine resident came to PACU postop to see a patient and told the nurse to give 50mg phenylepherine ivp. The PACU nurse knew enough to know that was wrong, asked if she meant mcg, and said she wouldn't give it without a physical computer order (med resident was trying to verbal). So the resident actually put the order in and the nurse draws up 5 vials and gives it push. Can't remember for sure but I think the systolic got to 300... Thankfully not my patient, and pt did ok

I’m surprised the computer allowed the resident to enter that dose.

 

[deleted162650]

I think the color coding of drugs may actually be a safety problem more than a solution.

Disagree. I think the the color coding of drug classes is a good thing. Obviously there is no substitute for reading the label and no excuse for drug swaps but . . . . if you accidentally give vec instead of roc, or ephedrine instead of neo, or atropine instead of glyco, the consequences are far less than if you give an obscene dose of an uber concentrated pressor when you meant to give an anti-emetic. Especially in the age of drug shortages where you get a new brand of the same drug on a weekly basis, there needs to be some consistency.

Get on it APSF.

 

[GravelRider]

Meanwhile the Joint Commission will get on your case for not putting your initials on a syringe or not putting hair nets on your eyelashes, but has nothing to say about this.

 

[T-burglar]

That looks indistinguishable from our milrinone bottles lol

 

[narcotics999]

Our decadron 5ml bottle has the similar color of amiodarone, and they sit next to each other in pyxis.

 

[caligas]

Disagree. I think the the color coding of drug classes is a good thing. Obviously there is no substitute for reading the label and no excuse for drug swaps but . . . . if you accidentally give vec instead of roc, or ephedrine instead of neo, or atropine instead of glyco, the consequences are far less than if you give an obscene dose of an uber concentrated pressor when you meant to give an anti-emetic. Especially in the age of drug shortages where you get a new brand of the same drug on a weekly basis, there needs to be some consistency.

Get on it APSF.

I imagine the anesthesia drug equivalent of this for every vial:

 

[deleted162650]

I imagine the anesthesia drug equivalent of this for every vial:

View attachment 242123

I love the clarity and simplicity, but still think it should be color coded.

 

[Twiggidy]

Disagree. I think the the color coding of drug classes is a good thing. Obviously there is no substitute for reading the label and no excuse for drug swaps but . . . . if you accidentally give vec instead of roc, or ephedrine instead of neo, or atropine instead of glyco, the consequences are far less than if you give an obscene dose of an uber concentrated pressor when you meant to give an anti-emetic. Especially in the age of drug shortages where you get a new brand of the same drug on a weekly basis, there needs to be some consistency.

Get on it APSF.

Agree

 

[Ronin786]

Color coding works if it's strictly adhered to and there is a uniform policy behind each color and the drug. That doesn't exist currently, and as a result color coding potentially introduces more error.

 

[Twiggidy]

One thing our pharmacy does a half decent job of is having our pressor vials in the drawer away from less lethal vials in a separate drawer.

 

[deleted162650]

Color coding works if it's strictly adhered to and there is a uniform policy behind each color and the drug. That doesn't exist currently, and as a result color coding potentially introduces more error.

Agree. This is something that really should be standardized in the industry.

You listening ASA and APSF???

 

[abolt18]

To make it worse, there's been accounts at multiple hospitals of pharmacies mistakenly stocking their drug trays with phenylephrine vials in the spots allocated/labeled for zofran.

We just had this happen the other day where octreotide was placed in the slot for zofran in a tray. Same green top.

 

[Ronin786]

We just had this happen the other day where octreotide was placed in the slot for zofran in a tray. Same green top.

Why do you need octreotide in the OR?

 

[abolt18]

Why do you need octreotide in the OR?

We don't... That's the problem. It was placed in the tray by accident in the slot where zofran goes.

 

[vector2]

Agree. This is something that really should be standardized in the industry.

You listening ASA and APSF???

Yet somehow label makers everywhere have standardized colors. Why can't purple for pressors, yellow for anesthetics, blue for opioids, orange for benzos, red for paralytics, green for anticholinergics be the standard for both labels and vial caps?

 

[TheLoneWolf]

So if your new resident or crna accidentally pushes the 10mg of phenylephrine and you are called in. What would mgmt be? NTG bonuses then gtt? I had not used phentolamine or phenoxybenzamine in residency and doubt its commonly stocked in the pyxis.

 

[Psai]

Yet somehow label makers everywhere have standardized colors. Why can't purple for pressors, yellow for anesthetics, blue for opioids, orange for benzos, red for paralytics, green for anticholinergics be the standard for both labels and vial caps?

That just makes too much sense. Id rather have my zofran switch up green and blue every other month

 

[Arch Guillotti]

So if your new resident or crna accidentally pushes the 10mg of phenylephrine and you are called in. What would mgmt be? NTG bonuses then gtt? I had not used phentolamine or phenoxybenzamine in residency and doubt its commonly stocked in the pyxis.

Let it wear off. NTG if it doesn’t.

 

[MirrorTodd]

Let it wear off. NTG if it doesn’t.

Y'all not using clevidipine? Or is that too expensive/I'm an idiot who doesn't know what I'm talking about?

 

[Ronin786]

So if your new resident or crna accidentally pushes the 10mg of phenylephrine and you are called in. What would mgmt be? NTG bonuses then gtt? I had not used phentolamine or phenoxybenzamine in residency and doubt its commonly stocked in the pyxis.

Its incredibly short acting, fire up the sevo or give a propofol bolus. Standard hypertension management.

 

[Dejavu]

It's not like there are a million different colors to choose from for the drugs that we use routinely.

This doesn’t work so well if you are red-green colour blind. I know, “Then read the labels”, and we all should.

Years back there was a push for one-colour labeling to force practitioners to read each label. A slow down in emergent situations for sure, but the idea does have its merits.

I’m just commenting that colour coding is not the solution for all people.

 

[Monty Python]

Considering how many things in anesthesia are standardized (PISS and DISS systems, vaporizer colors, liquid volatile bottle label colors, gas tubing colors, etc), it's not unreasonable to expect the manufacturers to follow a uniform system for vials. If they don't, perhaps the FDA will force it upon them.

I foresee a requirement in the near future to scan each vial's barcode when taking from a drawer. We currently don't have the system to do that but it's rumored to be coming. It would capture the vial usage for patient charge, inventory management, and also double-checking that what you just scanned is indeed what you meant to obtain by showing the med and concentration on the screen. Assuming pharmacy accurately entered that information in the database in the first place, and also put the proper vial in the proper drawer bin. No, pharmacy errors never happen. Currently our phenylephrine and toradol vials are EXACTLY the same size, cap color, label colors and label fonts. Twice in the last two weeks the pharmacy techs have put the wrong vials in the wrong bins. While I hate to get officious and bureaucratic, at what point do we start submitting official patient safety reports to risk management versus the periodic phone call to the chief pharmacist? I know, pick your battles wisely, but this is really annoying (and potentially dangerous).

 

[TheLoneWolf]

Considering how many things in anesthesia are standardized (PISS and DISS systems, vaporizer colors, liquid volatile bottle label colors, gas tubing colors, etc), it's not unreasonable to expect the manufacturers to follow a uniform system for vials. If they don't, perhaps the FDA will force it upon them.

I foresee a requirement in the near future to scan each vial's barcode when taking from a drawer. We currently don't have the system to do that but it's rumored to be coming. It would capture the vial usage for patient charge, inventory management, and also double-checking that what you just scanned is indeed what you meant to obtain by showing the med and concentration on the screen. Assuming pharmacy accurately entered that information in the database in the first place, and also put the proper vial in the proper drawer bin. No, pharmacy errors never happen. Currently our phenylephrine and toradol vials are EXACTLY the same size, cap color, label colors and label fonts. Twice in the last two weeks the pharmacy techs have put the wrong vials in the wrong bins. While I hate to get officious and bureaucratic, at what point do we start submitting official patient safety reports to risk management versus the periodic phone call to the chief pharmacist? I know, pick your battles wisely, but this is really annoying (and potentially dangerous).

We had this at the VA. You enter the pts name into the machine and it unlocks the drawers. When you pull a med, you usually had to manually scan it on some machines. Others, you just touched the screen to inventory. All returns had to be scanned.

 

[anbuitachi]

our ondansetron looks the same as Vasopressin. Both orange caps

 

[jwk]

Disagree. I think the the color coding of drug classes is a good thing. Obviously there is no substitute for reading the label and no excuse for drug swaps but . . . . if you accidentally give vec instead of roc, or ephedrine instead of neo, or atropine instead of glyco, the consequences are far less than if you give an obscene dose of an uber concentrated pressor when you meant to give an anti-emetic. Especially in the age of drug shortages where you get a new brand of the same drug on a weekly basis, there needs to be some consistency.

Get on it APSF.

It's likely been discussed before - this is a decades-long problem with no end in sight.

There are good arguments both pro and con for color coding. The color that makes the most sense to me is the bright red/orange for NMBs. But just as color-coding may be good for some things, it's not good for others. There are significant differences between morphine, hydromorphone, fentanyl, sufentanil, alfentanyl, remifentanil, demerol, methadone, etc., yet in our place, every one of them is the same pale-blue labeling.

Best practice is READ THE LABEL! I still catch myself pulling the wrong vial out of a drug tray, and as already noted, the problem is worse with the never-ending changing of generics. Nothing beats reading the label. Period. Any other reason you have for giving the wrong drug because the vial/label/cap color looked the same/similar to something else means you simply were not being vigilant.

 

[Mman]

It's likely been discussed before - this is a decades-long problem with no end in sight.

There are good arguments both pro and con for color coding. The color that makes the most sense to me is the bright red/orange for NMBs. But just as color-coding may be good for some things, it's not good for others. There are significant differences between morphine, hydromorphone, fentanyl, sufentanil, alfentanyl, remifentanil, demerol, methadone, etc., yet in our place, every one of them is the same pale-blue labeling.

Best practice is READ THE LABEL! I still catch myself pulling the wrong vial out of a drug tray, and as already noted, the problem is worse with the never-ending changing of generics. Nothing beats reading the label. Period. Any other reason you have for giving the wrong drug because the vial/label/cap color looked the same/similar to something else means you simply were not being vigilant.

While I agree that in an OR it is up to that person to read the label, from a patient safety/system design point of view humans will make mistakes. We need to try to design systems to minimize their ability to make those mistakes.

 

[nimbus]

It's likely been discussed before - this is a decades-long problem with no end in sight.

There are good arguments both pro and con for color coding. The color that makes the most sense to me is the bright red/orange for NMBs. But just as color-coding may be good for some things, it's not good for others. There are significant differences between morphine, hydromorphone, fentanyl, sufentanil, alfentanyl, remifentanil, demerol, methadone, etc., yet in our place, every one of them is the same pale-blue labeling.

Best practice is READ THE LABEL! I still catch myself pulling the wrong vial out of a drug tray, and as already noted, the problem is worse with the never-ending changing of generics. Nothing beats reading the label. Period. Any other reason you have for giving the wrong drug because the vial/label/cap color looked the same/similar to something else means you simply were not being vigilant.

I understand your point about reading the label but all blue for opioids is a good start. Likewise purple for pressors makes sense. What is the argument against purple caps for phenylephrine, ephedrine, and vasopressin? Then it’s less likely there will be a swap between phenylephrine and zofran or reglan. Standardized color coded caps would make things marginally safer although we still need to be vigilant.

 

[deleted697127]

Considering how many things in anesthesia are standardized (PISS and DISS systems, vaporizer colors, liquid volatile bottle label colors, gas tubing colors, etc), it's not unreasonable to expect the manufacturers to follow a uniform system for vials. If they don't, perhaps the FDA will force it upon them.

I foresee a requirement in the near future to scan each vial's barcode when taking from a drawer. We currently don't have the system to do that but it's rumored to be coming. It would capture the vial usage for patient charge, inventory management, and also double-checking that what you just scanned is indeed what you meant to obtain by showing the med and concentration on the screen. Assuming pharmacy accurately entered that information in the database in the first place, and also put the proper vial in the proper drawer bin. No, pharmacy errors never happen. Currently our phenylephrine and toradol vials are EXACTLY the same size, cap color, label colors and label fonts. Twice in the last two weeks the pharmacy techs have put the wrong vials in the wrong bins. While I hate to get officious and bureaucratic, at what point do we start submitting official patient safety reports to risk management versus the periodic phone call to the chief pharmacist? I know, pick your battles wisely, but this is really annoying (and potentially dangerous).

Buyer beware. This all works in theory until the brand new label makers break, the systems don’t communicate consistently, or the new drug suppliers barcodes dont scan and need to be individually reprogrammed by pharmacy in each OR. I’m sure some day the system will be perfected but i wouldn’t be surprised if the solution is reinvesting and buying the next generation Pyxis in 5 years.

 

[jwk]

I understand your point about reading the label but all blue for opioids is a good start. Likewise purple for pressors makes sense. What is the argument against purple caps for phenylephrine, ephedrine, and vasopressin? Then it’s less likely there will be a swap between phenylephrine and zofran or reglan. Standardized color coded caps would make things marginally safer although we still need to be vigilant.

Many of our more-common drugs are pre-fills. For example - Phenylephrine and ephedrine are both in pre-filled syringes with the same light purple official color-coded labeling. Ditto for atropine and glyco with light green labeling. Not hard to see that those could easily be confused in a rush.

 

[nimbus]

Many of our more-common drugs are pre-fills. For example - Phenylephrine and ephedrine are both in pre-filled syringes with the same light purple official color-coded labeling. Ditto for atropine and glyco with light green labeling. Not hard to see that those could easily be confused in a rush.

But confusing 2 drugs of the same class with similar effect is not as bad as something like swapping phenylephrine for reglan. That’s one of the benefits of standardized color coding.

 

[polar403]

Many of our more-common drugs are pre-fills. For example - Phenylephrine and ephedrine are both in pre-filled syringes with the same light purple official color-coded labeling. Ditto for atropine and glyco with light green labeling. Not hard to see that those could easily be confused in a rush.

Same here, but the pre-filled syringe for phenylephrine is 10cc and ephedrine is 5cc.

We had the same issue with phenylephrine and ondansetron at my shop. We just had the phenylephrine vials loaded into a pop-out drawer in the Pyxis rather than one of the pull-out drawers with lots of drugs. Easy fix.

I don’t understand why anyone would pull a vial of phenylephrine and “accidentally” inject it instead of ondansetron. It’s a lack of attention. I don’t know anyone that pulls up that vial in an emergent situation and pushes 1cc. So, the issue is that they don’t pay attention to the vial label nor do they pay attention to the volume they pull out. Seems like they need to re-evaluate their workflow.


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[pgg]

I don’t understand why anyone would pull a vial of phenylephrine and “accidentally” inject it instead of ondansetron. It’s a lack of attention. I don’t know anyone that pulls up that vial in an emergent situation and pushes 1cc. So, the issue is that they don’t pay attention to the vial label nor do they pay attention to the volume they pull out. Seems like they need to re-evaluate their workflow.

Of course it's a lack of attention. But that's not really the point. It's still an error with potential to cause harm.

There is a wealth of very good data, in and out of medicine, that system and engineering controls reduce errors. Including errors that humans shouldn't make, and maybe wouldn't make if they had perfect workflow habits.

Gas lines don't need pin index connectors, the O2 flowmeter knob doesn't need to be different than the air/N2O, pulse oximeters don't need to be audible. If people just had perfect workflow habits no one would hook up wall nitrous to a machine's O2 inlet, and desatting patients would be detected instantly because eyes would be glued to the monitor.

It is ridiculous that there is no industry wide standardization of how drugs are packaged. Given how many of our drugs are manufactured overseas, I understand the origin of the problem and the difficulty of the solution. But better "workflow" habits isn't the answer.

 

[polar403]

Of course it's a lack of attention. But that's not really the point. It's still an error with potential to cause harm.

There is a wealth of very good data, in and out of medicine, that system and engineering controls reduce errors. Including errors that humans shouldn't make, and maybe wouldn't make if they had perfect workflow habits.

Gas lines don't need pin index connectors, the O2 flowmeter knob doesn't need to be different than the air/N2O, pulse oximeters don't need to be audible. If people just had perfect workflow habits no one would hook up wall nitrous to a machine's O2 inlet, and desatting patients would be detected instantly because eyes would be glued to the monitor.

It is ridiculous that there is no industry wide standardization of how drugs are packaged. Given how many of our drugs are manufactured overseas, I understand the origin of the problem and the difficulty of the solution. But better "workflow" habits isn't the answer.

I agree that we should do everything to reduce errors and that there should be standardization of how drugs are packaged. Better workflow habits should not be the only answer, but it should still be part of the answer. We can’t expect everyone/everything else to change because we refuse to.


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[Psai]

Of course it's a lack of attention. But that's not really the point. It's still an error with potential to cause harm.

There is a wealth of very good data, in and out of medicine, that system and engineering controls reduce errors. Including errors that humans shouldn't make, and maybe wouldn't make if they had perfect workflow habits.

Gas lines don't need pin index connectors, the O2 flowmeter knob doesn't need to be different than the air/N2O, pulse oximeters don't need to be audible. If people just had perfect workflow habits no one would hook up wall nitrous to a machine's O2 inlet, and desatting patients would be detected instantly because eyes would be glued to the monitor.

It is ridiculous that there is no industry wide standardization of how drugs are packaged. Given how many of our drugs are manufactured overseas, I understand the origin of the problem and the difficulty of the solution. But better "workflow" habits isn't the answer.

I am a big fan of the DISS and PISS systems. I propose a new system called pharmacopoeia officiale operativa physic or POOP for short. Medication caps will be color coded in accordance with their sticker color to minimize preventable errors.