Newly Published
Images in Anesthesiology  |   August 2019
Drug Label Ribbons to Improve Patient Safety in Low-resource Environments
Author Notes
  • From the Department of Anesthesiology (M.P.) and the Department of Obstetrics and Gynecology (C.E.A., L.K., C.M.), Baylor College of Medicine, Houston, Texas.
  • Correspondence: Address correspondence to Dr. Prin: meghan.prin@gmail.com
Article Information
Images in Anesthesiology / Patient Safety
Images in Anesthesiology   |   August 2019
Drug Label Ribbons to Improve Patient Safety in Low-resource Environments
Anesthesiology Newly Published on August 14, 2019. doi:10.1097/ALN.0000000000002918
Anesthesiology Newly Published on August 14, 2019. doi:10.1097/ALN.0000000000002918
These images demonstrate the operating room medication labeling system of a public referral hospital in Malawi (left image) and a new system being piloted by the authors in a district hospital of Malawi (right image).
Many systems have been developed to prevent medication administration errors, including standardized color-coded labels, two-person verification, operating room pharmacists, and adverse event reporting systems.1  However, very few of these are feasible in low-resource settings. Even color-coded tape is often unavailable or unaffordable. As demonstrated in the far-right of the left image, the underlying tray labels are often relied on and the syringes themselves may remain unlabeled. In most low-income countries, adverse event reporting systems are absent, which limits the ability to monitor errors. A recent meta-analysis of medication errors in anesthesia practice in sub-Saharan Africa found only five case reports and seven studies.2  Most reported errors are substitution errors, and the most common causes are syringe swapping or mislabeled syringes.1,3