Reducing the potential for adverse drug events has been a key initiative for U.S. healthcare facilities for several years, but what is the cause of the problem? Is it incorrect documentation? Failure to diagnose the correct illness? These are all questions raised by the healthcare professionals in this realm.

Study Reviews Perioperative Medication Errors

A study conducted by Harvard-affiliated Massachusetts General Hospital (MGH), Department of Anesthesia, Critical Care, and Pain Medicine made interesting discoveries and insights on these very questions. A group of specially trained members of the research team observed 275 surgeries and 225 anesthesia providers (anesthesiologists, nurse anesthetists, and resident physicians) during these operations. Through the observational study, it was found that in every second operation and in 1 in 20 perioperative medication administrations, a medication error and/or an adverse drug event (ADE) occurred. Observed patient harm was the result of more than one third of the errors and there was potential for patient harm for the other two thirds.

These rates sound alarmingly high. What happened (or didn’t happen) to create such a disturbing outcome? How could these errors occur in such a stringent environment? It appears there a few more items on the checklist that need revisiting. The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patient’s vital signs, and documentation errors.

The Most Common Medication Error Discovered

Labeling errors were the most common medication error type and represented 24% of the overall medication errors. An example of a labeling error is a missing phenylephrine label which has a potential ADE of wrong dose or drug error. 30% of the medication errors were considered significant, 69% serious and less than 2% were life-threatening, none were fatal. The overall medication error rate of 5% was the same among all members of staff, including anesthesiologists, nurse anesthetists, and residents. The study also found that these errors and adverse drug events occurred more frequently during longer procedures, especially those lasting more than six hours and involving 13 or more medication administrations.

Since the origin of these errors had not been investigated prior to this study, the results provided guidance for where change was most needed. Karen C. Nanji of the MGH Department of Anesthesia, Critical Care, and Pain Medicine stated, “We definitely have room for improvement in preventing perioperative medication errors, and now that we understand the types of errors that are being made and their frequencies, we can begin to develop targeted strategies to prevent them.”  These strategies will need to include various comprehensive decisions prior, during, and after surgeries to ensure that all risk of error is removed.

Now that these alarming statistics have come to light, what solutions are available to mitigate the risk? As most of the errors coincide with properly documenting patients, tools, and medication, one simple solution that can be used to reduce the risk of medication errors is accurate labeling. Implementing proper labeling solutions for medications will help ensure that the correct medication and correct dose is administered to the patient and help meet the elements of performance for The Joint Commission’s NPSG.03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Medication Labeling Solutions Can Help Reduce Errors

There are a wide variety of medication labeling solutions available to help perioperative and OR clinicians accurately identify medication and improve patient safety. These include:

Sterile medication labels and kits include pre-printed labels for the most commonly used medications, such as Lidocaine, Epinephrine, Marcaine, Heparin, etc. along with fields for strength, expiration date, and expiration time so that clinicians can quickly and easily label syringes. This helps ensure that physicians and clinicians can identify the medications prior to administration.



Time Out labels are used as reminders for clinicians to follow The Joint Commission’s Universal Protocol and to conduct a pre-procedure verification process to verify the correct patient, procedure, site, and implants before the start of a procedure is a critical patient safety. Affix this label to patient record to document compliance with The Joint Commission’s Universal Protocol.

Syringe flag labels are specially designed to identify smaller medication syringes without obscuring the syringe or its contents. There are blank, printable labels that can be printed with a laser printer or thermal printer. There are also pre-printed flag labels with fields for caregivers to handwrite drug identification information.



With all of the complicated risks associated with surgery, accurate labeling of medication is one area where preventing errors can be easy. Identification labeling is the simplest solution to help prevent medication errors because labels help caregivers correctly identify and communicate medications to prevent confusion or mistakes in administration.

Perioperative Perspective: Labeling Errors Are the Most Common Type of Medication Error
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Perioperative Perspective: Labeling Errors Are the Most Common Type of Medication Error
With all of the complicated risks associated with surgery, accurate labeling of medication is one area where preventing errors can be easy.
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PDC Healthcare
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Jess Johnson is the Senior Brand Manager for Healthcare at PDC, helping to communicate to healthcare customers how PDC solutions can help them with workplace and patient safety. She joined PDC in 2019, with a background in B2B marketing communications and content creation. Jess has Marketing and Journalism degrees from Miami University in Oxford, OH. Originally from Northeast Ohio, Jess now lives in Santa Clarita, CA with her husband and pit-lab mix, Cashmere.


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