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Risks with drug labels used in preparation of medicines in pediatric hospitals

Background:

Dosing and preparation of medicines can be challenging and risky. Therefore, drug labels are often used by healthcare personnel when preparing medicines for hospitalized patients. There is a lack of information on how the labels should be designed and how much information they should contain. However, the National Board of Health and Welfare has required that all labels need to contain seven attributes.

Aim:

The purpose of this study was to analyse risks associated with labels used in pediatric care, and to investigate which attributes a standardized drug label should contain to increase patient safety.

Methods:

A survey was answered by pharmacist from different hospitals in Sweden. In addition, the pharmacists were asked to send pictures of labels. A risk analysis was performed to calculate the risk-level of identified label attributes. 

Results:

Different systems are in use for labeling when preparing medicines in Swedish hospitals, including commercial and self-developed systems. The study showed that none of the 54 collected labels complied with the National requirements. However, many labels contained additional attributes. This study identified 18 different label attributes that had different impact on patient safety as valued by pharmacists working in pediatric wards, for example barcodes to quickly look up important information.

Conclusion:

It is important to optimize labels used in hospitals when preparing medicines, particularly in pediatric care where the usage of off-label drugs and medication errors are common. Further studies are needed to understand the best design of labels and to increase patient safety in pediatric care.