How IV Line Identification Labels Reduce Administration Errors, Boost Patient Safety

9/6/2024

Errors can still take place during the medication administration process, despite various advances in technology — such as the use of smart pumps and barcoding — helping address these concerns. In fact, according to a report by the Agency for Healthcare Research and Quality (AHRQ), intravenous (IV) administration is especially problematic, exhibiting a much higher rate of medication errors compared to other procedures performed in hospitals and long-term facilities. 

One key to more effective medication administration is the proper labeling of IV line tubing. In their “Recommendations to Enhance Accuracy of Administration of Medications” report, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) states that healthcare professionals should only administer medications that are properly labeled, and labels should be read during the following steps in the administration process: 

• Reaching for/handling the medication
• Preparing the medication
• Immediately before administering the medication
• Discarding the container or replacing unused medication in its storage location

Multiple IV lines, infusions increase complexity

Managing a single IV and line is straightforward, but when multiple IV bags and lines are involved, the complexity increases. As a result, establishing best practices for labeling IV line tubing becomes even more critical.

According to a Pharmacy Practice News report analyzing errors associated with multiple IV lines:

• The most common errors associated with multiple IV infusions are: infusion rate or line mix-ups, IV lines not attaching to patients, and errors associated with piggyback infusions
• High-alert medications were involved in 71% of all multiple IV infusion errors and 92% of all IV line mix-ups
• Using the NCC MERP scale, 48% of incidents were categorized as harm score D or greater, and 6.2% were categorized as harm score E or greater
• Nearly all (95%) of the errors reached the patient

Without ongoing vigilance, hospitals risk a sentinel event — a patient-safety event that can result in severe temporary harm, permanent harm, or death to a patient. However, when the systems design and internal protocols include the use of IV line and identification labels and training on how to correctly label IV line tubing, unintended errors can be reduced. In fact, IV line identification labels assist the medical staff and guide the right dose at the right time by the right route.

The role of IV line identification labels

Utilizing IV line identification labels can help manage the proper flow of medication into the IV lines. This ensures:

• Dispensing the same drug — a label placed at the top of the line and/or closest to the insertion point helps ensure proper dispensing
• Same dose — because medication dosage is often changed from shift to shift, noting the dose on line and bag will safeguard consistent medication management
• Time managed — start and end times are critical to ensure the patient receives proper medication dosage

In addition, labeling the IV bag with the appropriate medication label makes connecting the right IV line to that bag much simpler. Plus, consistent color-coding patterns can help the staff verify that lines are properly connected.

Labels can also play an important role in IV changes. Standard protocols require regular IV changes to prevent infection, and a change reminder label can alert the medical staff to change it on a specific day or date. In addition, when the information on a change reminder is used in conjunction with the drug type and medical chart, it helps guide the staff on appropriate patient actions. For example, when medication is added to the IV, noting the medication in several places ensures the communication will be seen by all caregivers.

Safe handling of hazardous drugs 

IVs can present additional risks when used to administer hazardous drugs (HDs). To address these risks and other challenges associated with handling HDs, the U.S. Pharmacopeia (USP) developed guidelines in their USP <800> chapter. The chapter recommends implementing policies to ensure safe handling such as:

• Separating IV HDs from other areas
• Clearly labeling the items with special handling instructions
• Using an externally ventilated, negative-pressure room with at least 12 air changes per hour (ACPH)

In addition, if transportation occurs outside the facility, safety data sheets (SDS) and labels detailing HD storage and disposal instructions are required. Developed to protect the environment, healthcare workers, and patients from exposure to hazardous agents, the USP <800> guidelines became official in November of 2023.

Providing a positive impact

Effective labeling is also an important element of the National Patient Safety Goals issued by The Joint Commission, which evaluates healthcare facilities for consistency, medication safety, and sentinel events. IV line identification labels can help healthcare organizations maintain consistency, improve patient safety, and meet The Joint Commission standards.

IV line identification labels assist in medication administration and simplify a variety of medication management processes. These labels can have a positive impact on medication administration errors that can be common across all healthcare settings. As a result, your healthcare facility can reduce the potential for mistakes.

The information presented in this blog was originally published by RRD’s United Ad Label (UAL), which has extensive experience with IV line labeling. RRD United Ad Label regularly works with healthcare organizations to understand how to properly label IV line tubing, and help ensure that Joint Commission standards and internal protocols are met.