What’s New in the Patient Safety World


October 2007


Pennsylvania PSA Advisory on Drug Labeling and Packaging



The September 2007 Patient Safety Advisory from the Pennsylvania Patient Safety Authority has another excellent article about medication errors related to drug labeling and packaging.


The advisory gives numerous real examples of such errors with pictures of many of the confusing labels. A particular problem seems to be confusion in the way the drug’s strength or concentration is displayed on the label. This especially is a problem with multi-dose vials. They show the packaging on Kenalog-40 preparations side by side. One is for a 1 mL vial, the other a 5 mL vial. The respective labels say “40 mg” and “40 mg per ml”. The latter vial is often incorrectly interpreted to contain a total of 40 mg rather than the actual 200 mg. One facility’s solution is to store the different sized vials in separate areas in the pharmacy, stock only the 1 mL vials in other areas of the facility (including Pyxis machines), and use bar code technology to scan prior to stocking.


Since so many medication errors seem to involve multidose vials, we strongly recommend facilities always ask themselves why they ever need a multidose vial of a medication in areas other than the pharmacy. There may be circumstances where a multivial dose of a medication is needed but in most cases it is not really necessary and can only predispose to errors. All too often decisions about purchasing are made without input from the multiple disciplines that will actually be using the medications in their respective areas.


The advisory also discusses problems with medications whose concentrations are labeled as percentages or dilution ratios, and problems related to color-coding schemes.


The advisory also discusses the role of confirmation bias. They note that recent healthcare graduates initially read labels carefully but after time they begin to rely on appearance of familiar products and become less vigilant in reading labels.


They also provide several practical risk reduction strategies including:

They recommend reviewing the literature regularly to help identify problem-prone products. And they stress the importance of including information about contributing factors such as labeling and packaging when facilities report medication errors to regulatory agencies or other error reporting systems.


This is another outstanding contribution by the Pennsylvania PSA, ECRI, and ISMP.









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