Magnification to avoid medication errors

As to disease, make a habit of two things - To help, or at least to do no harm.

-Hippocrates (Epidemics, Book I, Ch. 2)

INTRODUCTION

Medication errors are the most common errors harming at least 1.5 million people every year.[1,2] Medication errors were estimated to account for 7000 deaths in the USA in 1993.[3] The reasons for misidentification of a drug can be - look alike/sound alike drugs, syringe swap, confusing, inaccurate, or incomplete drug labels, small print, damaged labels, poor background colour, etc.[2] Cognitive impairment with small prints increases with age. Forty percent of young adults and 96% of older adults reported need for glasses. With this in mind, we decided to study the accuracy of drug label identification by staff in operating theatres and Intensive Care Units (ICU).

METHODOLOGY

Ten drugs, 5 vials and 5 ampoules, were selected at random from amongst the drugs routinely used in the operation theatre (O.T) and ICU in a Tertiary Care Hospital [Table 1]. Twenty members of the staff working in the O.T and in ICU, including doctors, nurses, and trained technicians were asked to identify each drug, its concentration, and the expiry date from the label. Each member of the staff was alone with the two investigators during the exercise, where one handed the drugs to the subject in a random way and the other recorded the time taken to identify the three values, using the same digital stopwatch. None of the subjects were given any time for prior preparation. Inaccuracy in any one value was considered as an inaccuracy in the whole reading. All the subjects who had prescription glasses were allowed to use them. After another 2 weeks, the test was repeated using a proper magnifying glass of 5X magnification.

Table 1.

List of vials and ampoules

RESULTS

With regard to fastness of reading [Table 2], the average time taken to read the labels on 10 drugs without magnification but using own prescription glasses was 9.3 s/drug. With improved magnification, the average time taken was 6.06 s/drug and 7 out of 20 subjects improved across the 10 readings, 5 subjects improved over 9 readings, and 4 subjects improved over 8 readings. Thus, improvement was seen in 16 (80%) subjects when improvement in more than 8 readings was considered.

Table 2.

Speed and accuracy of reading the label

In the first instance, without magnification but using own prescription glasses, 17 subjects out of 20 (85%) made a total of 28 (14%) mistakes in 200 observations, that is, an accuracy rate of 86% [Table 2]. With good magnification (5X), the accuracy was 100%. As a small side test, a number of the subjects were asked to locate the magnifier supposed to be kept at a fixed location on the OT trolley. They took an average of 10 min to locate the same because it was not always present where expected or the subject was unaware of the correct location.

DISCUSSION

Many factors contribute to mistaking of one medication for another. The medication may be stored in the wrong location, or the clinicians may select the medication based solely on the appearance of its package.[2,4] Confusion can occur between medications with names that look alike or sound alike or between pre-mixed medications packaged in similar-looking containers.[4,5]

Another potential source for confusion with pre-mixed medications is the presence of different concentrations of the same medication in a particular location (e.g., a package with a 100 mg/ml concentration of a drug could be mistaken for 1 with a 10 mg/ml concentration).[2] The size and fonts on the labels can be a cause for confusion particularly when the container is small. Small prints/text on drug labels not only cause eye strain, but more importantly can lead to wrong drug, wrong dosage, or wrong route of drug administration.

Most of the recommendations made by various authors are aimed at the improvements to be made in the drug labels by the pharmaceutical industry, which though ideal, is difficult to ensure particularly in a country like India.

In our study, the speed at which a drug was identified improved considerably when a magnifying glass was used. Moreover, the accuracy of the readings improved dramatically with magnification. The test to locate the magnifier has shown that most subjects were either unfamiliar with its location or that the magnifier was not always where it should have been located.

We recommend the following to minimise medication errors:[1] A magnifying glass of good quality should be provided in all places in a hospital where emergency medication is practiced.[2] The magnifying glass should be accessible, and personnel should know the location. It can be affixed to the trolley such that it cannot be removed to any other location.[3] People working in this situation must be made familiar with the drugs, vials, ampoules, etc., through regular training programs.[6] Familiarity with the English language must be encouraged because at the moment all labels are in English.[7] In case more people are unfamiliar with the language, then some alternative methods should be found to avoid confusion between drugs with similar sounding names and labels.[8] All drugs on the trolley must be assigned a fixed place, and personnel must be familiar with this fact.

CONCLUSION

Drug labels are not always unambiguously readable. The size and colour of the labels and the font size therein are important reasons for reading errors. Familiarity with the printed language on the labels is important. A magnifier improves accuracy dramatically and also improves speed while reading a drug label.

Financial support and sponsorship

GHRC.

Conflicts of interest

There are no conflicts of interest.