Poor ampoule colour coding?

The focus on non-luer lock spinal needles is commendable [1]; however, the packaging and presentation of drug ampoules has also been shown to contribute to drug administration errors in anaesthesia [2]. We wish to highlight a case of what we think is a poor modification to a drug ampoule design. The ampoules used in our hospital for 0.5% hyperbaric bupivacaine (Marcain® Spinal 0.5% Heavy, Astra Zeneca, North Ryde, NSW, Australia) have recently had a coloured ring added to the top of the ampoule (Fig 4). New (left) and original (right) ampoules. In light of recent trends toward safer labelling and alterations to equipment to reduce the risk of incorrectly administering intravenous and neuraxial drugs [3], we question the choice of a blue ring on an ampoule for a drug that is intended to be used solely via the intrathecal route. The international trend in labelling of neuraxial drugs is to use yellow as the identifying colour for ‘containers or conduits’, with Australian authorities now recommending that labels are yellow for neuraxial and blue for intravenous use [4]. The standard for user-applied syringe labels depends on the class of drug in the syringe, with grey or Pantone 401 the standard for local anaesthetics [5, 6]. This could have been used as the rationale for a grey ring on the ampoule. We feel that this choice of colour has the potential to confuse the user and increases the risk of a medication error. We have written to the manufacturer to suggest removing the coloured ring or changing it to a yellow one.