How Can You Avoid Mistakes Caused by Look-alike Bags?

A potentially fatal medication error almost occurred at a Veterans Affairs hospital when surgical team members mistook a 500-ml IV bag of lidocaine for a 500-ml IV bag of hetastarch. Which method would have been most effective in differentiating the look-alike labels on the bags?

a. tallman lettering

b. bold text

c. inverted text

d. lowercase text

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Answer: c

After the close call, researchers at the VA Pittsburgh Healthcare System decided to test the effectiveness of replacing standard labels on IV bags with customized labels, which were printed on white opaque paper to improve print legibility over clear drug containers, featured inverted text (white lettering on a dark background), and noted only key drug information — the name, strength, administration route, and warnings — on the front panel to avoid word clutter and confusion. During a simulated emergent surgery, the researchers placed hetastarch bags — first with standard labels, then with enhanced labels — in an anesthesia cart’s drawer along with a bag of lidocaine. Anesthesiology students and nurse anesthetists in training were 2.5 times more likely to grab the correct bag when the enhanced labels were used, noted the researchers (J Patient Saf. 2015. doi: 10.1097/PTS.0000000000000176).
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Study lead author Jamie L. Estock, a human factors psychologist at the VA Pittsburgh Healthcare System, said the exercise provided additional evidence to support the use of opaque white labels on clear medication containers and demonstrated the effectiveness of inverted text for highlighting key medication information. She also noted that pharmacists within her health system used the findings to redesign labels they place on operating room medications that are compounded in-house and said other pharmacies could do the same. Redesigning a single product within a complex healthcare environment can have a significant impact on patient safety, according to Dr. Estock, who said future medication safety initiatives should focus less on fixing the practices of individual providers and more on redesigning the products they use and the environments in which they work.