JRSM > Volume 97, Number 10 > Pp. 506

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Medication errors and confusion over labelling

Roxane J Hillier   Simon P Kelly

Royal Bolton Hospital, Bolton BL4 0JR, UK

Dr Wheeler and his colleagues (August 2004 JRSM¹) make a strong case for standardized labelling to avoid confusion over ratios and percentages in drug solutions. May we draw attention to another potential source of confusion in relation to drug labelling. The unlabelled ampoule in Figure 1, which we presume to have contained Betnesol (betamethasone), was taken out of its packaging during routine cataract surgery for planned periocular injection. Theatre staff reacted appropriately by discarding it, and we reported the incident to the Medicines and Healthcare products Regulatory Agency. We also advised the manufacturers. The absence of a label was due to a manufacturing error, fortunately not coupled with the loss of coloured bands which do help to distinguish it from other products. However, this picture illustrates another potent source of error. Even when intravenous medications are correctly labelled, the similarity between their appearances is an example of a latent or potential systems failure.

View larger version (102K): [in this window] [in a new window]   Figure 1. An assortment of ampoules, including one accidentally unlabelled. Colour version available on [www.jrsm.org]

 

REFERENCES

1. Wheeler DW, Remoundas DD, Whittlestone KD, et al. Doctors’ confusion over ratios and percentages in drug solutions: the case for standard labelling. J R Soc Med2004; 97:380 –3[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Send a Quick Comment Alert me when this article is cited Alert me when Quick Comments are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hillier, R. J Articles by Kelly, S. P Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?