Doctors must read drug labels, not whinge about them

Editor—Twice last year the BMJ gave column space to doctors reporting confusion between ampoules of water, saline, and lignocaine (also called lidocaine) for injection.¹,² These doctors blame the similarity in ampoule shape and colour rather than admitting to the fundamental problem of having simply failed to read the label.

In my view, the differences between the labels in both the illustrations used are readily apparent.¹,² To blame that labelling is a diversion of personal responsibility that I find unacceptable; even for doctors “in a busy plastic surgery unit”² the check takes only a second. The journal is right to draw attention to the issue, but the arguments against change need to be presented as well.

Those who clamour for change must recognise that there are only a few shapes (round, square, and triangular in cross section) that might be used to hold fluids, and only a few colours (black, white, violet, indigo, blue, green, yellow, orange, and red) that might be used for labels (many combinations are ineligible if the lettering is to be legible). The range of injectable drug preparations (remember that variations in volume and drug concentration must be dealt with too) far outnumbers the possible combinations of usable colours and shapes. Thus responsibility will always lie with the user to read the label before use.

Introducing shape and colour differences will undoubtedly increase manufacturing costs but do nothing to reduce the need for this fundamental check or reduce the number of errors. It might even increase the errors if clinicians thought that they were absolved from the responsibility of reading carefully what is on the label.