A nurse prepared a dose of aminophylline, 75 mg, for a patient who was about to undergo a dipyridamole (Persantine) stress test but didn't label the syringe. Aminophylline is used to reverse the effects of dipyridamole if the patient develops bronchospasm, but it wasn't needed during the procedure. After the procedure, the nurse stepped out of the room as a nuclear medicine technologist entered to administer an I.V. dose of radioisotope to the patient. The unlabeled syringe was placed where saline flushes were normally kept, and the technician used it to flush the patient's I.V. line. Fortunately, the patient wasn't harmed.

The Joint Commission Medication Management Standard MM.4.30 requires labeling all medications. Yet a survey by the American Nurses Association indicated that only 37% of nurses surveyed reported that they always label syringes and 28% never label syringes when administering medications.1

These measures can help reduce risks associated with unlabeled syringes:

* pharmacy dispensing of ready-to-administer injectable products in labeled syringes as prescribed for each patient

* using prefilled syringes labeled by the manufacturer

* providing commercially available syringe labels in all drug preparation areas and letting nurses choose a standard format that best meets their needs. Tape isn't suitable for labeling syringes.

* developing label placement guidelines so that labels don't obscure the syringe contents and gradations on the syringe barrel or impede syringe function

* using syringes with safety features such as a write-on stripe for recording critical information on the syringe barrel with a nonsmear pen

* discarding all unlabeled syringes and reporting the event as a hazardous condition.

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