Syringe labelling – an international standard

Most will now be aware that the Association of Anaesthetists and the Royal College of Anaesthetists have recommended implementation of a standard in labelling syringes for use in anaesthesia, intensive care and other critical care areas, including Accident and Emergency. This began at the beginning of May. Many may ask why it was felt necessary to recommend this change. Applying labels to syringes with the name of the drug thereon has long been practised in the UK. Originally, the drug name was written on adhesive paper applied to the syringe. Later, properly printed labels were produced, usually black on a white background. Blank labels were also produced so that more unusual drugs could still be ‘written’ on to the syringe label. Over the last decade or more, colour-coded syringe labels have been produced in the UK. The labels are preprinted with the drug name and groups of drugs, e.g. opiates or relaxants, have their own colour as a secondary method of avoiding drug errors. Interestingly, in a paper written as recently as 1999 [1] all methods described above are still in existence in the UK. Therein lies the problem. There is no recognised standard for the UK. In another recent paper, Christie & Hill [2] declare that the majority of units use the Medilabel® system, but this is still not a recognised standard. Do we need a colour-coded labelling system for syringes? Do we need it to be standardised? In April 2001, ‘Building a Safer NHS for Patients’– implementing ‘An Organisation with a Memory’ was published by the Department of Health. The principle of this document was that lessons should be learned from adverse events and the NHS should benefit from this. In response to this, the Committee of Safety of Medicines (CSM) established a Working Group on the Labelling and Packaging of Medicines in an attempt to try and reduce drug errors. A working document was produced and the Association of Anaesthetists and Royal College of Anaesthetists were invited to comment. Although the document was mainly concerned with standardising the labelling of medicines, both packs and ampoules, secondary labelling of drugs in syringes was also considered. It was felt that standardisation was a good idea both for ampoules and syringe labelling. The former would take time to implement within the pharmaceutical industry but the latter might be amenable to quicker implementation. Where is the evidence of need? Giving the wrong drug during anaesthesia is commoner than most would imagine. Webster et al. [3] put the figure as high as 1 in 133. Most of the errors are of little consequence. Some, such as giving a relaxant instead of an opiate, may have more severe consequences. Fortunately, mortality as a result of drug error is rare. Ten years ago in a study by Currie et al. [4], 2000 drug error incident reports were examined with no consequential mortality. The same study showed ‘syringe swap’ as a major cause of drug error. In 63% of cases of syringe swap the drug was correctly labelled. Labels, whether coloured or not, will never totally prevent drug errors. Some have found little evidence that changing from black and white labels to colour makes a difference to the incidence of drug error [5]. The USA and Australia have been largely ahead of the game when looking at critical incidents in this area of medical practice. Systems failure is the key phrase. In order to prevent a critical incident, no single facet will aid prevention, rather a collection of strategies [4, 6]. Colour is a major psychological cue and most regard the use of colour as helpful rather than detracting. Even though the evidence is scanty, it is interesting to note from Christie's paper that the majority of UK units use a colour system. Why change to the Australasian and North American system? The suggestion of standardisation came about as described above, when responding to the CSM Working Group on Labelling and Packaging of Medicines. There were three obvious alternatives: To develop a UK standard To develop a European standard To recommend adoption of the Australasian and North American standard. A UK standard could have been developed from the Medilabel® system as many units were using it. However, many anaesthetists move between different departments both in the UK and abroad. The development of a ‘Little Englander’ standard was not thought to be appropriate however easy and desirable. Those of us who have attended European Standards meetings in other areas will be aware of the extraordinary length of time it takes to get a standard accepted throughout Europe. We saw no reason why this would be different in this instance. This left us with the idea that there was a system started in the USA in 1994, adopted in Australasia in 1996 and in Canada in 1999, which was up and running. In addition to this, our enquiries at the Common Interest Group meeting held annually of relevant societies of the UK, America and Australasia had indicated no major problems with the change. Everyone was happy with the system as it stood. We therefore decided to recommend this colour-coding system. Councils of both the Association of Anaesthetists and Royal College of Anaesthetists are unanimous in their support. Subsequently, the Intensive Care Society and Faculty of Accident & Emergency Medicine have given the standard their support. Introduction of a standard is never an easy task. The main manufacturers have provided labels from 1 May 2003. The major manufacturer has stated that old labels will no longer be produced by them after the end of this year. Anaesthesia News and the RCA bulletin have carried information earlier in the year and information is available both on AAGBI and RCA websites. Clinical directors and purchasers of labels in all trusts have been informed, as have all the Private Hospitals. Each institution will have slightly different stock levels of old labels. It is not for us to dictate how an individual trust should make the change. The important points are that the change should be made as soon as possible so there is little national discrepancy and that within one institution two differing systems should not run side by side. Some of the new colours may be direct opposites to what is currently being used in a particular institution and vigilance is needed at this time. The most important discipline is that the correct drug is drawn up into the syringe. The second is that a correct label is placed on that syringe. Issues of colour of the label are of secondary importance. They are just part of a system, a psychological cue, or a guide, as described above!

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