The odds of a clinician selecting the correct medication during a simulated medical emergency are more than twice as high when medication labels are designed to be read easily, researchers find.
Labels on bags of IV fluids that are designed to be easy to read in a medical emergency can prevent medical errors and save lives, suggests a recent study recently published in the Journal of Patient Safety.
The study looked at a group of 96 anesthesia trainees, who, in a simulated medical emergency, were asked to administer hetastarch, a blood plasma volume-increasing fluid, to a patient who was losing blood.
In the fluid drawer of each participant’s surgical cart were three bags of hetastarch and one of the anesthetic drug lidocaine, simulating a potentially deadly stocking error.
Participants were randomly assigned carts containing bags with either labels designed by the team conducting the study, which were opaque with the name of the drug contained in white on a blue field with inverted text, or bags bearing current labels, which are transparent, on a glossy bag with the drug’s name and information in blue or red letters.
Participants were blinded to the study’s focus on medication label design and their assigned label condition. Each participant was the sole anesthesia provider in the simulated operating room scenario involving an unexpected vascular injury. Each was asked by the surgeon to administer hetastarch to the patient to minimize blood loss.
The trainees with access to the fluid bags with the redesigned labels were more likely to select the correct medication, and more likely to notice their error if they initially reached for the wrong medication, researchers found.
Jamie L. Estock, MA, human factors psychologist at the VA Pittsburgh Health System, the study’s lead author, had hypothesized that the study would yield these results. “While the clinician is administering the IV bag, they’re thinking about other things. They are worried about the patient, stopping the blood loss, [and] what they will do next,” she says.
More than 60% of trainees correctly chose the hetastarch bag when the redesigned labels were used, compared to about 40% when the standard labels were used. On statistical analysis, the odds of selecting the correct medication were more than twice as high with the redesigned labels.
Striving to End Medical Errors
The Institute of Medicine estimates as many as 98,000 US deaths yearly in hospitals due to medication errors. “It’s not just wrong drug— sometimes it’s the wrong route, the wrong patient,” explains Estock.