Introduction of a nationwide standardised coloured user-applied drug label for high-risk anaesthetic drugs.

Background and goal of the study: Anaesthetic drug error is a recognised source of patient harm. Misidentification of drugs due to similar packaging or labelling is an important cause of drug error.1 Currently, there are no standardised labels for anaesthetic drugs in the Netherlands and many hospitals have their own colour-coding of anaesthetic drug labels.1 However, many anaesthesia providers are working in multiple hospitals. This increases the likelihood of drug error through misidentification of drugs by relying on the wrong colour scheme. We designed and implemented a standardised label for high-risk anaesthetic drugs in the Netherlands.

Materials and methods: We designed the labels using the colours from the ISO standard, and the ISMP Tall Man Lettering system in order to reduce medication errors within the same group. A QR code for electronic registration and double check was added. The implementation process followed the implementation steps as described in the NICE guidence.2  We send email notifications through the Dutch society of Anaesthesia and several national conferences were organised. A Prospective Risk Analysis was done. An e-learning was created to familiarise staff with the new labels. 

Results and discussion: The Academic Medical Centre Amsterdam was one of the pilot hospitals that started using the labels. The introductory e-learning was completed by 88% of staff. Ninety-four percent felt that the e-learning was helpful to explain the system behind the labels. A voluntary survey after using the labels was completed by 68 members of staff, and most common criticism was the likeness of certain colours, especially during scopic surgery as ambient light is switched to green. This problem was addressed and the colours were intensified. During the 3-month introduction period of the new labels, 7 minor drug errors were reported in 4715 anaesthetic actions. The Dutch Society for Anaesthesia now recommends the use of these labels nationwide.

Conclusion: To reduce patient harm it is imperative to reduce anaesthetic drug error. We describe the successful design and implementation of standardised labels resulting in a nationwide recommendation to use these labels. The impact of standardised labels on patient outcomes has to be determined in future.

References
1. Preckel B et al. Labelverschillen leiden tot medicatiefouten. Med Contact 2014: 2345-7.
2. How to put NICE guidance into practice. http://www.lumsa.it/sites/default/files/UTENTI/u492/nice.pdf

Introduction of a nationwide standardised drug label for high-risk anaesthetic drugs