Every syringe or drug container that reaches the sterile field must carry a label that clearly notes the drug's name and concentration, expiration date and time, and the preparer's name or initials. Yes, so much information on such a tiny label, especially if your OR personnel are testing the limits of good penmanship by handwriting the labels rather than using pre-printed or custom-made ones.

Vicki Sullivan RN, CNOR, MHA, of Kingsland Surgery Center in Katy, Texas, is being kind when she says, "Being able to read the handwriting of all the surgical scrubs is a challenge."

Perhaps the greatest challenge is getting the OR staff to consistently get everything on the label that's supposed to be there. "I hate to have to monitor and remind anesthesia and the OR techs to label, but left on their own, neither group would label," says Joanne Robichau, RN, CNOR, CASC, of Teton Outpatient Services in Jackson, Wyo.

Barriers to proper labeling
Whether you properly label medications some, most or all of the time is not the point here, although your Medicare or accreditation surveyor will certainly take great interest in your syringe-labeling practices. Here are 3 roadblocks to proper medication labeling you might face:

• Administer first, document later. Any pharmacy consultant will tell you that it serves only to protect you and not your patients if you apply the label after you've administered the drug. Document, then administer: That's the proper order when giving drugs in surgery. But it's not uncommon for anesthesiologists to complete the label after they've given the medication, or to partially label the medications that they've drawn up ahead of time. But as Mena Reese, RN, CAPA, of Presidio Surgery Center in San Francisco, Calif., points out, "the label is incomplete because there is no patient name on it."
• 'I know it's propofol.' Some staff might not see the importance of labeling drugs. "Changing attitudes and old practices can be difficult," says Sue McNamee, RN, of Green Spring Station Endoscopy in Lutherville, Md. "We use mostly propofol and the medication is either drawn up right before the procedure or a case ahead. It's white and the only medication that we have like that, so it's a why-bother? attitude."
• Time pressures. You can see the scrub tech fidget as he's labeling the syringe at the last second while the surgeon holds out his outstretched hand.

For Heather Hampton, RN, BSN, of the Sheridan (Wyo.) Surgical Center, none of these factors is a legitimate excuse for not properly labeling medications. "For me, it's like putting on your shoes," she says. "If you have to do it, do it right — all the time. It's comforting for me to know that somebody is paying attention to what they're giving."

Pre-printed and custom-made labels
Could pre-printed and custom-made labels turn a task as tedious and as prone to error as handwriting labels into a highly reliable and repeatable one?

Nearly half (44%) of the 54 surgical facility managers we polled last month use color-coded labels pre-printed with the drug's name and concentration. All they have to do is initial it, date it and time it. Ten use custom-made labels (we didn't ask about commercially pre-filled syringes). Twenty use a waterproof marker — smudge-free, we hope — to write medication labels in the sterile field. A few mix and match, using pre-printed labels for higher-use medications administered in pre-op and PACU, and using plain labels with ink for drugs used on the sterile field.

"Trying to write in a sterile environment sterilely all the time is a pain," says Leroy Kromis, PharmD, BCPS, medication safety officer at Lehigh Valley Hospital in Allentown, Pa. "If you want people to do something, you have to make it easy for them to do the right thing. If it's going to be hard to label, you're going to have poor compliance."

Of all your labeling options, computer-generated labels might be your safest choice. They're also the most expensive. One popular system that sells for about $8,500 features a touch-screen computer, 2D bar-code scanner, color ink-jet printer and audio feedback. It weighs about 15 pounds and is the size of a breadbox. You must first enter your facility's formulary; you can configure the formulary to include dilutions/diluents for each drug. You scan the vial's bar code and visual confirmation is displayed on a touchscreen with simultaneous audible feedback of the drug name and concentration. Seconds later, the machine dispenses a ready-to-apply, full-color label that contains the drug name, concentration, preparer's name or initials and expiration date and time. The labels display drug names in a 12-point font and provide formulary-controlled Tallman lettering for sound-alike/look-alike drugs.

Sterile labels are another option. They're sold with various amounts of information already printed on them. You can get them with drug name and strength pre-printed or just the drug name, with a pre-printed area and space for the provider to add the date, time and initials. Pre-printed labels with blank areas for required information could encourage compliance with medication labeling because empty areas remind the person preparing the syringe or solution of the missing information that needs to be added.

You can also buy pre-packaged drugs to avoid the challenges of labeling altogether. At Lehigh Valley Hospital, Dr. Kromis buys some patient-controlled analgesia products (fentanyl, morphine and Dilaudid) pre-made. The drugs not only come labeled, but also have longer expiration dates (45 to 60 days) than had he prepared the drugs at the hospital pharmacy (7 to 14 days). "It will cost you more," says Mr. Kromis, "but look at the conveniences."