A patient chart contains important information pertaining to an individual’s duration of stay at a specific healthcare facility. The record houses a variety of notes entered by professionals over this period of time. It contains facts such as medical history or allergies along with any recorded observations. This record has to be accurate and labeled appropriately to avoid confusion, as it will be the first item referred to when seeing the individual. Additional types of information written or placed on the patient chart are:
Various types of helpful data may be included on one patient chart from past pregnancies to habits. This information ensures the individual receives the best care. If an allergy is not noted or a condition has not been pointed out, it could result in the person receiving the wrong drug or treatment. Patient chart labels are your first line of healthcare professional communication.
Labels essentially offer a convenient pre-printed way to convey this data to health professionals. Before, it was common to handwrite every piece of information and to use forms filled out by the individual or person who checked them in. It is sometimes hard to read these forms and important facts do not always stand out. Additionally, a number of professionals will be viewing and adding information to this record. Patient chart labels provide a convenient way to record data while the individual is in their charge.
Color-coded markers placed at the top of this record are one of the most common types. They typically contain the room number, person’s name, and assigned doctor. While this is the typical marker attached to a chart, these other items are a possibility for conveying important information:
A number of labels are available outside of the ones used to identify the patient on the record. For example, allergy markers may be applied with a specific color to ensure existing sensitivities are easy to view. Another option is to use special patient chart labels to communicate certain restrictions or instructions. This could be one of the following types of markers:
Any label is a potential item for patient records and many are color-coded to make the information easy to spot. While not everything will need to be marked in this way, specific facts like drug sensitivities, allergies, and special care needs make it easier for each professional viewing the individual’s chart.
At Shamrock Labels, we want to make certain you receive every necessary label for effectively communicating patient information. We offer a wide range of patient chart labeling options from traditional strips for top placement to several informational items like the ones mentioned above. With over 45 years of experience, our goal is to provide the best customer service, minimal waste, and the products necessary to help your professionals excel in healthcare. Contact us today at (800) 323-0249 or fill out a Get In Touch form and we will be right with you!
The evidence is clear that labeling syringes, medicine cups and basins correlates to improved safety. Those little stickers will help your clinical teams avoid medication errors. Here's a guide to help you make sure that medications are properly labeled in your facility.
Any drawn medication the provider sets down on or off the sterile field should be properly labeled. Syringes require 5 labeling elements: drug, strength, date, time drawn and the initials of the person who prepared the syringe.
Labels are sold with various amounts of information already printed on them. You can get them with drug name and strength pre-printed or just the drug name. Additionally, labels are now available at minimal additional cost with a pre-printed area and space for the provider to add the date, time and initials. Pre-printed labels with blank areas for required information encourage compliance with the medication labeling requirements because empty areas remind the person preparing the syringe or solution of the information that needs to be added.
Besides syringes, other preparations such as intravenous minibags with antibiotics should be similarly labeled. In addition to the drug, strength, date, time drawn and the initials of the person who prepared the bag, I recommend that the preparer add the patient's name to the medication label, as is done in hospitals. For minibags, place IV additive labels on the face of the bag below the manufacturer's label printed on the bag so that the printing on the bag can be read as well.
In eye surgery facilities, prepared solutions such as balanced salt solution with epinephrine should have a label affixed to the container. In the GI suite, solutions of simethicone should be explicitly labeled, whether they're prepared in a pour bottle or a basin.
PRODUCT ROUNDUP Medication Labeling Products
SLS Smart Label System by Codonics
Available by year's end, this system helps improve adherence to the medication-labeling guidelines of the Joint Commission and the American Society of Anesthesiologists. It fits on an anesthesia cart and lets the anesthesia provider prepare a label and fill a syringe at the same time. By scanning a drug vial's bar code, it gathers the drug's name and strength, which the anesthesia provider confirms on the screen. The printer creates an easy-to-read, full-color label with the medication name, concentration, date and time prepared, date and time of expiration, initials of the preparer and a unique bar code that identifies the syringe. The bar codes can be configured for integration into your anesthesia information management system or electronic medical record system. Each label is colored appropriately to meet the ASA color-coding standards for medication labels. You can also create labels for IV lines and invasive monitors.
www.codonics.com
Anesthesia-Rx Cart by McKesson
This new anesthesia cart automates the medication dispensing and labeling process. With just 2 taps on the touch screen, the anesthesia provider can log into the system, unlock the cart and select the patient and needed medication. The corresponding storage bin in the cart's medication drawer automatically opens. The cart's software can connect to your facility's formulary to improve medication charge capture. The cart also has an optional bar-code scanner and a printer that automatically generates a medication label for syringes.
www.anesthesia-rx.com
Beyond-use date labels
Although healthcare facilities should be moving away from using multiple-use vials wherever possible, some medications used in the perioperative setting are still stocked in multi-dose vials, such as succinylcholine, rocuronium, labetalol and insulin. Multiple-dose vials need to be labeled with the "beyond-use date" to accommodate compliance with the "28-day rule," which addresses how long a facility can keep an opened vial before having to discard it. The person who initially breaks the seal should write the date 28 days later, rather than the date when the seal was broken. This will save time for co-workers down the line. If the person writes the date the seal was broken, each person who draws a dose will then need to calculate when the 28-day period ends.
Of course, there are exceptions. Succinylcholine and rocuronium may be stored at room temperature only for specific periods. Succinylcholine can be stored for 14 days and rocuronium can be stored for 60 days unopened and 28 days opened. Thus, labeling on these drugs should address these restrictions. Also, when the manufacturer's expiration date comes before 28 days, consider the earlier date the beyond-use date. Finally, any multiple-use vials used during an emergency in the OR should be discarded regardless of their beyond-use dates because their sterility may have been compromised during the emergency.
Keep it more than clean
Like everything else in the sterile field, medication labels created in the sterile field should be sterile, too. Any syringe drawn in the sterile field should be labeled using a sterile label and a sterile marker. Label manufacturers offer sterile and non-sterile pre-printed labels as well as single-use sterile pens.
Pre-printed labels come with varying amounts of information on them. You'll notice that some companies say that the labels are "custom" if you request strengths pre-printed. Pre-printed strengths on labels is common and you may be able to find them at a lower price from another manufacturer. Shop around before you pay a premium price.
Also check with your anesthesia provider to make sure that strengths printed on the labels are those most often used in your facility. The anesthesia provider should approve the labels based on your current formulary as well as routine dilutions, if any, that they use. Keep a stock of blank labels for physicians who use uncommon strengths.
The person who first opens a vial or who fills the syringes should create and place the label. No one else should do the labeling. Be firm in training staff that no one should ever label something prepared by someone else. ?
ASA Standards for Color Coding Medication Labels
Agent
Color
Induction agents
Yellow
Benzodiazepines and tranquilizers
Orange
Benzodiazepine antagonists
Orange with white diagonal stripes
Muscle relaxants
Fluorescent red
Relaxant antagonists
Fluorescent red with white diagonal stripes
Narcotics
Blue
Narcotic antagonists
Blue with white diagonal stripes
Major tranquilizers and anti-emetics
Salmon
Narcotic-tranquilizer combinations
Blue
Vasopressors
Violet
Hypotensive agents
Violet with white diagonal stripes
Local anesthetics
Gray
Anticholinergic agents
Green
Source: American Society of Anesthesiologists, Statement on the Labeling of Pharmaceuticals for Use in Anesthesiology, 2004 and 2009. www.asahq.org/publicationsAndServices/standards/38.pdf
Monitoring compliance?
Like hand hygiene, surgical-site marking or instrument reprocessing, medication labeling is a patient safety issue that's on the minds of surveyors and regulatory agencies. Medication errors, the fifth most common sentinel event, are considered preventable "never events" by the National Quality Forum, the Joint Commission and CMS. As a result, CMS, which has embraced the stringent APIC guidelines for safe injection, infusion and medication vial practices, and professional organizations have raised the bar on their expectations for pre-drawn syringes and infusions. AORN says that no unlabeled medication should enter the sterile field. "Label all medications, medication containers, and other solutions off the sterile field even if only one medication is involved," says the organization in its 2006 guidance statement, Safe Medication Practices in Perioperative Practice Settings.
It's not enough to ask your staff to label medications. You must monitor compliance. Observe, unannounced, how and when medications get labeled and who does it. Your compliance can then be benchmarked against other facilities' performance. In the end, the more you pay attention to medication labeling, the more your compliance will improve. As a result, those little sticky things will become powerful tools to ensure patient safety.
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