CCI Institute for Excellence: NPSG Requirements for Labeling of Syringes

By Stephen M. Dorman, M.D.

The requirement for the labeling of syringes became part of Joint Commission surveys as one of the National Patient Safety Goals 3. The reason for this NPSG is related to the number of avoidable events that have harmed patients. One recent case involved CRNA #1 preparing medication for CRNA #2. As a result of either mislabeling or no medication hand-off, a drug to reduce intraoperative bleeding was injected into the subdural space instead of bupivacaine. The courts found in favor of the plaintiff, who was severely impaired by the event. The outcome was tragic, because following a few basic steps could have prevented this event. Complacency leads providers down a path that may result in a mistake being made.

While the NPSG is surveyed as part of Joint Commission surveys, the principle of complying with this goal is to reduce risk to patients even for those hospitals that are not accredited by TJC.

This paper will discuss the elements of performance of NPSG 3.0: Label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings.

Element of Performance 1

 … label medications and solutions that are not administered immediately. This applies even if there is only one medication being used.

The note on this element states that it applies when there is no break in the process. Literally, once the medication is drawn up, it should be administered to the patient without any intervening, even setting the syringe down and making a computer note. Once it is, in any way, out of the provider’s hand, then you have interrupted the continuous process and it must be labeled.

Element of Performance 2

… labeling occurs WHEN any medication or solution is transferred from the original packaging to another container (or syringe). 

This element speaks to the fact that one medication must be labeled at a time. There can be no “batching” (filling multiples syringes) then labeling afterward. It also prohibits the “pre-labeling” of syringes unless they are filled immediately with medication. Pre-labeling of empty syringes is a common survey finding.

Element of Performance 3

…the label includes the following:

  • Medication or solution name
  • Strength (mg/ml)
  • Amount of medication in the container if not apparent from container
  • Diluent and volume if medication is diluted
  • Expiration date when not used within 24 hours (if permitted by hospital policy)
  • Expiration time when expiration occurs in less than 24 hours

Therefore, all labels need an expiration or “beyond use” time. Notice that there are no requirements for any sort of initials or identification of the person who is labeling. However, if this is hospital policy, it is applicable.

Element of Performance 4

Verify ALL medication labels both verbally and visually. Verification is done by TWO individuals qualified to participate in the procedure whenever the person preparing the medication or solution is not the person who will be administering it. 

This was the element that was violated in the case mentioned above. 

Practical note: this must also occur during any break relief. Have a medication “hand off” when providers are changing even for a short time.

Element of Performance 5

Label each medication AS SOON AS it is prepared unless immediately administered.

See EP 2 as it is very closely related. Immediately means absolutely no break between the process of filling to administration.

Element of Performance 6

Immediately discard ANY medication found unlabeled. (even Propofol).

Element of Performance 7

Remove all labeled containers and discard their contents at the conclusion of the procedure.

Exception: Multi-dose vials. (NOT Single Dose vials).

Element of Performance 8

All medications both on and off the sterile field and their labels are reviewed by entering and exiting staff responsible for the management of medication.

See EP 4 which is very closely related. Multiple elements may fail at this NPSG for one non-compliant process. Medication labeling is considered “high risk” in scoring and will require the hospital to address any survey findings in writing. If found in several places, it may warrant a focused survey.

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