D
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.
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 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.
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.
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.
We just had this happen the other day where octreotide was placed in the slot for zofran in a tray. Same green top.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.
Why do you need octreotide in the OR?We just had this happen the other day where octreotide was placed in the slot for zofran in a tray. Same green top.
We don't... That's the problem. It was placed in the tray by accident in the slot where zofran goes.Why do you need octreotide in the OR?
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?
Let it wear off. NTG if it doesn’t.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.
Y'all not using clevidipine? Or is that too expensive/I'm an idiot who doesn't know what I'm talking about?Let it wear off. NTG if it doesn’t.
Its incredibly short acting, fire up the sevo or give a propofol bolus. Standard hypertension management.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.
It's not like there are a million different colors to choose from for the drugs that we use routinely.
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).
It's likely been discussed before - this is a decades-long problem with no end in sight.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.
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.
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).
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.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.
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.
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.
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.