Study Urges Low-Tech Solutions for Medical Errors

SUNDAY Oct. 19, 2008 -- Standardizing the look of medication labels could significantly decrease costly and potentially harmful medication errors, a new study suggests.

Anesthesiologists at Penn State Hershey testing a simple color-coding system in simulated emergency room situations said the universal system could help prevent some of the 1.5 million adverse drug reactions each year caused by medication mistakes. These mistakes cost the health-care industry an estimated $3.5 billion annually.

In the study, which is to be presented Sunday at the annual meeting of the American Society of Anesthesiologists in Orlando, Fla., volunteer anesthesiologists, residents and nurses drew medications with different colored labels at an ever-increasing speed to mimic an emergency situation. When the color of the label on the syringe matched the color of the label on the medication bottle, fewer near-mistakes occurred compared to when the colors didn't match, though the number of actual mistakes was too low to make a comparison. When peel-off labels were taken off the bottle and placed on the syringe to be used, errors were reduced and fewer commands were skipped.

"Many 'high-tech' solutions have been suggested, including use of bar codes, radiofrequency identification for medications, and computerized medication administration processes," researcher Dr. Elizabeth H. Sinz, of the department of anesthesiology at Penn State Hershey, said in a news release issued by the society. "But besides their high costs, all of these methods have flaws that may produce as many errors as they eliminate. Furthermore, these solutions are often impractical for fast-paced situations in operating rooms or during emergencies."

"Simple systems, such as the color-coding methods used in our study, are more reliable and useable than complex systems," she said.

More information

The U.S. Food and Drug Administration has more about efforts to curb medication mix-ups.

Posted: October 2008


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