Using color-coded, peel-off labels to match medication vials and delivery syringes can sharply boost accuracy and efficiency during surgery, a team of anesthesiologists at Penn State University College of Medicine in Hershey, Pa., reports.

“The transfer of peel-off labels from medication vials directly onto syringes appears to have the potential to decrease both the error rate and the time required to transfer medications into syringes,” the researchers suggest.

The study tested three modalities in a simulated operating room: black-and-white labels and vials; colored labels that matched the vials; and peel-off labels from the vial pasted onto syringes. Trials consisted of prerecorded instructions that prompted a nurse, resident, or anesthesiologist to label and load a given amount of simulated IV medication at an ever-increasing pace to mimic the time pressures of actual surgery.

Two observers counted errors (wrong label or drug), omissions (skipped commands), and near-misses. When the tallies were averaged, the results showed participants made significantly fewer errors using peel-off labels than with black-and-white or color-matched labels (0.5 vs. 6 vs. 3.5, respectively). Peel-off labels also resulted in about half the omissions when compared with black-and-white or color-matched labels (68 vs.112 vs. 129.5, respectively).


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The researchers reported their findings at the American Society of Anesthesiologists 2008 annual meeting in Orlando. “This simple and relatively inexpensive technique deserves serious consideration to improve OR efficiency and, at the same time, enhance patient safety,” the team concludes.

“An average hospital patient may experience one medication error per day, contributing to 1.5 million preventable adverse drug reactions each year,” notes co-investigator Elizabeth H. Sinz, MD, associate professor of anesthesiology and neurology.

“Many high-tech solutions have been suggested, including the use of bar codes, radiofrequency identifications for medications, and computerized medication-administration processes. But besides their high costs, all of these methods have flaws that may produce as many errors as they eliminate.

“Furthermore,” she continues, “these solutions are often impractical for fast-paced situations in operating rooms or during emergencies. Simple systems, such as the color-coding methods used in our study, are more reliable and usable than complex systems.”