Standardisation, syringe labelling and prefilled syringes

‘Medication Without Harm’ is the WHO third Patient Safety Challenge [1]. Much of the knowledge is available, but needs to be consistently implemented. WHO’s three targets - high risk medications, polypharmacy and transitions of care - are what anaesthetists do all the time. Martin Bromiley, chair of the Clinical Human Factors Group, says “Standardisation has been shown to be an effective mechanism for reducing human error in complex processes or situations” [2]; medication processes are an area ripe for standardisation.

Labelling

The first medication standardisation in UK anaesthesia was introducing standard user-applied syringe labels in 2003, before which at least six different coloured label systems were in use [3, 4]. The specialty recommended standardisation using the existing Australian/ New Zealand/ USA labelling standards [5], and a survey of Association Linkpersons 12 months later found that more than 90% of hospitals were using them without any serious incidents during the change. This was a notable speciality-led achievement, with no lengthy regulation from the Department of Health or MHRA.

Label positioning

In 2007 the National Patient Safety Agency (NPSA) standard operating procedure for preparing injectable medicines advised labelling the syringe only after filling, not before [6]. This is logical as a label on an empty container can never be correct. It is consistent with other labelling practice, for example many serious incidents of incorrect blood samples for cross matching have occurred when the name label was placed on an empty sample tube [7]. The European Board of Anaesthesiology recommendations state: the syringe should be labelled immediately after filling and before leaving the operator's hand; the label should be matched with the ampoule; this should be done one medication at a time [8]. In a recent survey 61% of anaesthetists labelled syringes after filling, 21% before, and 18% had no standard process [9].

The syringe should be labelled so that the syringe contents can be identified before the clinician picks up the syringe. It is best practice to stick at least one label longitudinally along the barrel of the syringe so it can be read while the syringe is on the work surface. Similarly, syringes should always be placed oriented sideways so that they can be read easily. Standardised work trays using this orientation have been shown to reduce medication incidents [10].

A syringe label may be orientated either ‘left handed’ (nozzle pointing right) or ‘right handed’ (nozzle pointing left (Figure 1). Standardisation to ‘right handed’ is recommended, as this conforms with the orientation of syringe driver pumps, and labelling of prefilled syringes.

Prefilled syringes

When in the 1990s AstraZeneca produced both 1% and 2% propofol in prefilled syringes with a recognition tag in the flange to create a safety identity link to the Diprifusor syringe driver [11], anaesthetists thought that this the way all our drugs would be supplied in 10 years time. However, the specialty failed to grasp the initiative despite the NPSA recommending ‘purchasing for safety’ policies. There is probably no other healthcare area where so many human factor errors can be completely removed as with the adoption of prefilled syringes. Astonishingly, the NHS Specialist Pharmacy Service that advises hospitals on medicines purchase has no reference to human factors in their procurement overview [12].

Figure 1. Left Handed Syringe 

Right Handed Syringe

All drugs used in routine anaesthesia can now be supplied in prefilled syringes. Besides ensuring the correct contents, they can have a tamper-evident facility [13]. Sterility is also guaranteed; up to 6% of the syringes drawn up in operating theatres have bacterial contamination [14].

The latest Royal Pharmaceutical Society medicines guidance now includes a section for operating theatres [15]. The overriding themes are that manipulation of medicines in clinical areas should be minimised, and medicines should be presented as prefilled syringes or other ‘ready-to-administer’ preparations wherever possible. Using prefilled syringes permits the standardisation of drug concentrations for medicines that require dilution. Notably the London Nightingale Hospital pharmacy established a prefilled syringe compounding area [16], saving nurses time while wearing cumbersome PPE.

‘Wrongly prepared high-risk injectable medication’ used to be a Never Event, but none were reported and it was removed in 2015 [17]. NAP5 identified six ampoule labelling errors associated with awareness during general anaesthesia [18], but sadly this was never used to demonstrate the need for the robust systemic barrier of prefilled syringes.

In 2020 the WHO World Patient Safety Day was dedicated to health worker safety and proposed five goals for healthcare organisations [19]. One was ‘Prevent sharps injuries’, including maximising the use of needle-less intravenous systems. If intravenous access is already established, using safety engineered devices such as prefilled syringes offers this possibility. Preparing medicines with needles during transfers can often be difficult (Figure 2), and the Association transfer guidelines have recommended the preferential use of prefilled syringes since 2009 [20, 21].

The specialty of anaesthesia has been left far behind in the use of prefilled syringes. Of the 10 billion units of injectable medicines sold annually, 28% are supplied in ready to administer or prefilled preparations, yet in the acute sector this is only true for 4%. Surely anaesthetists, as the specialists in intravenous practice, should now be demanding this. Anaesthetists are accustomed to the standardisation of controls on anaesthetic machines and other equipment, but many have their own foibles or quirks for arranging the medication work surface. Standardisation is a powerful safety tool, and particularly potent when working in teams; I believe now is the time to introduce standardisation into perioperative medication practices.

David Whitaker 
Chair, Patient Safety Committee, European Board of Anaesthesiology 
Manchester

February 2021: the Association are finalising draft guidelines on 'Syringe labelling and peri-operative medicines handling', which will shortly be made available for Member and Stakeholder consultation. Please watch this space.

Figure 2.

Illustration: ‘In Safe Hands’ The Medical Emergency Response Team aboard a CH47 Chinook above Southern Afghanistan, battles to save the life of an injured soldier by Stuart Brown. With permission, Skipper Press LTD, www.skipperpress.com 

The original painting was donated to the Royal College of Anaesthetists by Colonel Peter F Mahoney OBE, TD, MSc, FRCA, L/RAMC Defence Professor

References 

1. Donaldson LJ, Kelley ET, Dhingra-Kumar N, Kieny M-P, Sheikh A. Medication Without Harm: WHO's third Global Patient Safety Challenge. Lancet 2017; 389: 1680-1. 
2. Union Européenne des Médicins Spécialistes. European Standardisation of the in-hospital 'Cardiac Arrest Call' Number - 2222, 2016. https://www.uems.eu/__data/assets/pdf_ file/0007/38644/Joint-Press-release-2222-20-9-2016-without-confidential.pdf (accessed 10/12/2020). 
3. Radhakrishna S. Syringe labels in anaesthetic induction rooms. Anaesthesia 1999; 54: 963-8. 
4. Christie IW, Hill MR. Standardized colour coding for syringe drug labels: a national survey. Anaesthesia 2002; 57: 793-8. 
5. Birks RJS, Simpson PJ. Syringe labelling - an international standard. Anaesthesia 2003; 58: 518-9. 
6. National Patient Safety Agency. Promoting safer use of injectable medicines. A template standard operating procedure for: prescribing, preparing and administering injectable medicines in clinical areas, 2007. https://www.sps.nhs.uk/wp-content/uploads/2018/02/2007-NRLS-0434F-Promoting-safeSOP-template-2007-v1.pdf (accessed 1/12/2020). 
7. Bolton-Maggs PHB, Wood EM, Wiersum-Osselton JC. Wrong blood in tube - potential for serious outcomes: can it be prevented? British Journal of Haematology 2015; 168: 3-13. 
8. Whitaker D, Brattenbø G, Trenkler et al. The European Board of Anaesthesiology recommendations for safe medication practice. European Journal of Anaesthesiology 2017; 34: 4-7. 
9. ESAIC Academy. Webcast on Medication Safety, 2020. https://academy.esaic.org/esaic/2020/elearning-2020/288282/prof.teodora-orhidee.nicolescu.prof.benedikt. preckel.doctor.jannicke.html?f=listing%3D0%2Abrowseby%3D8%2Asortby%3D1%2Asea rch%3DMedication+safety (accessed 3/12/2020). 
10. Grigg EB, Martin LD, Ross FJ, et al. Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study. Anesthesia and Analgesia 2017; 124: 1617-25. 
11. Gray JM, Kenny GNC. Development of the technology for ‘Diprifusor’ TCI systems. Anaesthesia 1998; 53: 22-7. 
12. Healthcare Safety Investigation Branch. Inadvertent administration of an oral liquid medicine into a vein, 2019. https://www.hsib.org.uk/investigations-cases/inadvertent-administration-oral-liquid-medicine-vein/ (accessed 3/12/2020). 
13. Association of Anaesthetists. Safe drug management in anaesthetic practice, 2020. https://anaesthetists.org/Home/News-opinion/News/Safe-Drug-Management-in-Anaesthetic-Practice (accessed 3/12/2020). 
14. Gargiulo DA, Mitchell SJ, Sheridan J, et al. Microbiological contamination of drugs during their administration for anesthesia in the operating room. Anesthesiology 2016; 124: 785-94. 
15. Royal Pharmaceutical Society. Professional guidance on the safe and secure handling of medicines. Appendix C: Operating theatres - supplementary guidance, 2018. https://www.rpharms.com/recognition/setting-professional-standards/safe-and-secure-handling-of-medicines/professional-guidance-on-the-safe-and-secure-handling-of-medicines (accessed 3/12/2020). 
16. Harchowal J. What a pharmacy team, 2020. https://twitter.com/jharchowal/status/1251424098317676546 (accessed 3/12/2020). 
17. NHS England. Revised Never Events policy and framework, 2015. https://www.england.nhs.uk/wp-content/uploads/2015/04/never-evnts-pol-framwrk-apr.pdf (accessed 10/12/2020). 
18. Pandit JJ, Andrade J, Bogod DG, et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089-101. 
19. World Health Organization. World Patient Safety Day Goals 2020-21, 2020. https://apps.who.int/iris/bitstream/handle/10665/334329/WHO-UHL-IHS-2020.8-eng.pdf (accessed 3/12/2020). 
20. Association of Anaesthetists of Great Britain and Ireland. Interhospital transfer, 2009. https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_interhospital_ transfer_2009_final.pdf?ver=2018-07-11-163754-600&ver=2018-07-11-163754-600 (accessed 3/12/2020). 
21. Nathanson MH, Andrzejowski J, Dinsmore J, et al. Guidelines for safe transfer of the brain injured patient: trauma and stroke, 2019: Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society. Anaesthesia 2020; 75: 234-46.

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