Monday, February 4, 2008

Color-coding - is this a good idea??

Back in Novemeber 2007 the two children of Dennis Quaid and his wife Kimberly, along with a third patient, were mistakenly given an overdose of heparin while at Cedars-Sinai Medical Center. The mixup resulted when the wrong strength of heparin vials was used, a 10,000 unit per ml vial instead of a 10 unit per ml vial. The Quaids subsequently are suing the manufacturer of the drugs, Baxter Healthcare, alleging that Baxter was negligent for making different doses in similar vials with similar blue labels. An attorney representing two families affected by previous overdoses as a result of labeling mix-ups says that these are not new problems and will likely continue, as human error is inevitable given the similar labeling on the two sizes of heparin vials.

Looking at their filing it appears that they feel that the label colors should have been different ("... Since a medical error in administration could lead to a dangerous or fatal result, the background colors should have been different."), as should also be the size and shape of the vials ("... Since a medical error... the vials should have been in completely distinguishable size and shape.")

OK, a couple of thoughts. Given the huge number of different drugs on the market, their varying dosage forms, their multiple strengths (e.g. heparin comes 1 unit per ml, 10 units per ml, 100 units per ml, 1,000 units per ml, 5,000 units per ml, 10,000 units per ml, 20,000 units per ml, etc.), the fact that their generic equivalents are often also manufactured by dozens of other manufacturers, it is fairly obvious that it is well nigh impossible for all possible variations to have different color labels and different shaped/sized vials... And, were such a system possible it would contribute to the natural tendency of folks to use color and/or shape and size as a proxy or 'shortcut'. It could well be argued that making every label color uniform would improve patient safety, as providers would then be obliged to actually read the label and confirm the drug/dose rather than rely on color or some other visual cue...

Bottom line, the Quaids are well-intentioned but misguided in this. They are not doing this for the money but "so that this doesn't happen to another child". However, they would be better to push for barcodes on unit of use and for the providers to have reader systems in place to use them!

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