Department of Pharmacy Policies & Procedures

Number: 5:23

Effective Date: 9/08

Revisions:

Reviewed: 11/09

Approval: September 2008

Subject: MEDICATION LABELING

A. POLICY

All medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field should be labeled.

This risk reduction activity is consistent with safe medication practices and

addresses a recognized risk point in the safe administration of medications

in perioperative and other procedural settings.

Errors, sometimes tragic, have resulted from medications and other solutions

removed from their original containers and placed into unlabeled containers.

Medications or other solutions in unlabeled containers are unidentifiable. This

unsafe practice neglects basic principles of medication management safety yet

has been routine in many organizations with respect to medications transferred

to the sterile field.

B. PROCEDURE

A standardized method for labeling all medications will minimize errors. Anytime one or more medications are prepared but are not administered immediately, the medication syringe/vial will be labeled with drug strength, date, time and secured in such a way that it can be readily determined that the contents are intact and have not expired.

At a minimum, all medications are labeled with the following:

§ Medication name, strength (concentration), and amount (if not apparent for the container)

§ Expiration date when not used within 24 hours

§ Expiration time when expiration occurs in less than 24 hours

§ For all compounded IV admixtures and parenteral nutrition solutions, the date prepared and the diluents

When preparing medications for multiple patients, or the person preparing the medications is not the person administering the medication, the label also includes the following:

§ Patient name

§ Patient location

In surgical or other procedural settings (OR, prep areas, pre-op holding, PACU,

medications used by anesthesia providers, radiology and other imaging services,

endoscopy units, and patient care units) where “bedside” procedures are done, when medications are drawn up and put on the sterile field for use during that specific procedure, at a minimum, the label will include the following:

• Medication name
• Medication strength (concentration)
• Medication amount (if not apparent from the container)
• Expiration date is required if the medication will not be used within 24 hours.
• Expiration time is required if the expiration will occur in less than 24 hours.
• Date prepared and preparer’s initials
• Any remaining medication must be discarded immediately after the case/

procedure

If, during the peri-operative or peri-procedural process, a solution or medication (either in the sterile field or out) is poured, drawn into a syringe, or otherwise used from it’s original container and immediately administered, or disposed of in some fashion, labeling is not required.

Whenever removing medication/solutions from original container, the original container must be kept in the room for the procedure

If the medication or solution that has been removed from its original container will be used over the course of a procedure, for instance – prep solutions, normal saline used to rinse cardiac valves, local anesthetics, clotting agents, etc. their receiving container must be labeled.