Letter to the Editor
I read the Pro/Con Debate: Color-Coded Medication Labels in the February 2019 issue of the APSF Newsletter with interest. I found that the companion article “Pro: Color-Coded Medication Labels Improve Patient Safety” provided a reasonable argument for use in clinical practice. However, there are several issues with the Con argument presented. First, Dr. Litman suggests that we should not use color coding because the variety of suppliers do not use the same coding. It would appear that if we accept this notion, we are accepting the present flawed dogma. National organizations may seek ways to urge producers of medications to consider standardizing the colors of their labels. The next reason quoted by Dr. Litman is that those providers that are colorblind will not be able to distinguish label colors. However, for those that are colorblind, it would seem that an emphasis on reading the printed label would be most prudent. This is something we are all expected to do anyway. Another argument proffered is that nurses outside of the operating room may not be familiar with color-coding. However, I see this as an opportunity to educate providers on the value of color-coding medications and standardizing this process throughout hospital care.
Several organizations have expressed concern about color-coding of medication labels. Yet none of them specifically address the high acuity of medication administration in the operating room. Seconds count in giving life-saving medications. Anesthesia professionals are hampered by lighting and patient positioning when administrating medications. This work environment is different from anywhere else in patient care. For good reason already, by federal regulation, medical gases must be labeled and color-coded (21 CFR § 201.328).
Organizations such as the Anesthesia Patient Safety Foundation should strongly assert their mission that “no patient shall be harmed by anesthesia care.” We need to emphasize our work with suppliers of medications and labeling devices to facilitate standardization of medication color labeling. Many industry representatives already ask for our guidance. We need to impress upon our purchasers of medications to only buy compliantly packaged medications, with labels and vial caps complying with the appropriate national guidelines on medication labeling.
H.A. Tillmann Hein, MD
Dr. Hein is founder and managing partner of Metropolitan Anesthesia Consultants, LLP, Dallas, TX, and clinical professor of Anesthesiology and Pain Management at The University of Texas Southwestern Medical School. He also serves on the Committee on Quality Management and Departmental Administration for the ASA.
Dr. Hein has no conflicts of interest pertaining to this article.
The purpose of the “Con” perspective was to emphasize the fallibility of reliance on color coding, and to bring awareness to the anesthesiology community that better technological advances (i.e. bar-coding devices) now exist. Although it is not substantiated by epidemiological evidence, it would seem that the combination of colored labels plus confirmatory bar-coding (or another similar technological solution) would be an ideal solution to minimize the incidence of syringe swap. Reliance on an anesthesia professional to prevent errors by always reading the name of the drug on the label each and every time is naive, as human error is not preventable, and arguably normal. We now have the ability to improve upon outdated and unreliable safety systems, and they should be used. The Institute for Safe Medication Practices (ISMP) has been a proponent of color coding with regard to the American Society for Testing and Materials (ASTM) standard for anesthesia professional applied labels and for outsourced syringes used in the OR. The caveat is that these same color-coded syringes are also not relied upon in other areas of the hospital by non-anesthesia personnel, where same-class syringe mix-ups have occurred. The consequences of an accidental syringe swap error on a hospital ward are likely to be far worse outside the continuously monitored operating room environment. The overarching message of our “Con” approach to color-coding should not be focused on whether or not the color increases or decreases syringe swap, but rather on the need for additional systems-based safety mechanisms (i.e., bar-coding) that provide additional safety to medication administration by anesthesia personnel.
Matt Grissinger, RPh, and Ron Litman, DO
Matthew Grissinger RPh, FISMP, FASCP, is director of Error Reporting Programs, Institute for Safe Medication Practices.
Dr. Litman, DO, ML, is medical director of the Institute for Safe Medication Practices and pro- fessor of Anesthesiology and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania and an attending anesthesiologist at the Children’s Hospital of Philadelphia.
Neither author has any conflict of interest pertaining to this article.
Editor’s Note: Our editor’s group modified the original title of the article from Matt Grissinger and Ron Litman to reflect the authors’ opposition to the reliance of providers on color coded syringes that may provide false reassurance. They do not oppose color coding altogether.