Color Coding, Labeling, and Evidence for Safety Gains

To the Editor Thank you to Jelacic et al.1 for their interesting paper evaluating the Codonics label system, which I enjoyed. However, I feel that 2 statements in their article are somewhat misleading. The authors state that it is important to understand that there is no universally accepted standard for syringe label content and color because guidelines have been published by many regulatory agencies. Although this is correct in terms of the fine print detail on labels (such as the barcode format or expiry date), it is incorrect when it comes to the most psychologically salient feature of drug labels—that of label color. The same set of colors, organized by class of drug, is now promoted internationally by all agencies. This is a significant step forward from the situation of a few years ago, when different color sets were in use in the same country and even within the same hospital—clearly an accident waiting to happen.2 We have subsequently shown evidence of the value of drug class–specific color coding. In a study of 74,478 anesthetic cases, potentially very dangerous syringe swap errors between drug classes were reduced by 66%, from 47 interclass swaps in an estimated 550,105 bolus drug administrations (0.009%) to 5 in 183,852 bolus drug administrations (0.003%), P = 0.01.3 Jelacic et al. also state that an anesthetic safety system developed by our group requires the use of all system features to show benefit. In fact, this safety system was specifically designed to be modular, and any module may be used in isolation or in combination with the others—many at little or no cost—without leaving the anesthesiologist worse off than when using conventional methods alone.4 In an observational study of this system, in 1075 cases, we showed an overall reduction in recording and drug errors of 21% (from 11.6 errors per 100 drug administrations to 9.1 per 100, P = 0.045). This benefit was seen with only 18% of participants employing all system features, thus demonstrating a strong “dose effect” for the system in reducing error. DISCLOSURES Craig S. Webster was involved in the development and assessment of the anesthesia safety system in references 3 and 4 of this letter, and owns a small number of shares in the company, which now offers it commercially. Craig S. Webster, MSc, PhD Centre for Medical and Health Sciences Education University of Auckland Auckland, New Zealand [email protected]