Case Study: Sutter Health Develops Custom IV Labels to Reduce Medication Errors


Developing Custom IV Labels to Reduce Medication Errors

Make the right thing to do
the easy thing to do.

This was the guiding principle for a successful IV labeling project that came out of the cardiovascular intensive care unit (ICU) at Sutter Medical Center in Sacramento (SMCS). Poorly labeled IV lines, especially in a higher acuity setting, make it difficult to properly identify medications which can directly impact patient care. Med-Surg Clinical Nurse Specialist Siobhan Geary, RN, CNS and Clinical Educator Marlene Cook, RN, CVSICU knew there had to be a better IV labeling solution, and they turned to Shamrock Labels to design a custom label to reduce medication errors and improve patient safety.

Research & Development for Custom IV Labeling Project

Unsatisfied with the IV labeling they had, Geary and Cook created a vision for what they wanted with the help of evidence based guidelines and best practices from the Association for the Advancement of Medical Instrumentation (AAMI) and the Institute for Safe Medication Practices (ISMP).

But they still didn’t know how to make their vision a reality: “Our staff had a concern and a solution, but they did not know how to get from their ideas to implementation and standardization,” Cook said. That’s where Shamrock Labels came in. Through Shamrock’s custom labeling solution, Geary and her team worked closely with Shamrock’s Customer Care experts to identify the appropriate customization options.

The SMCS team developed a solution consisting of pre-printed, flag-style labels that would be placed on both tubing and pumps. After some initial trial and error, they chose a 5/8” x 4” label size with capital lettering to ensure legibility. Shamrock’s Customer Care experts also encouraged them to use a removable adhesive, making the labels strong and durable, but also easy to remove when no longer needed. This saved staff members the time and frustration of scraping label residue off of IV pumps.

They also opted not to utilize color coding, a trend in healthcare. Instead, they made the labels white with black text because, according to the ISMP, people are more likely to read the labels this way.

Medication administration is such a high-risk process, that anything we can do to make it easier for the nurse to perform safely, the better.

Putting The New IV Labels to the Test

Once Geary and the team landed on the desired label design, they launched a trial of the new IV labels starting in February of 2018. In addition to using them in the SMCS’ high acuity cardiovascular surgery ICU, they also implemented them in a smaller adult ICU at Sutter Davis Hospital. In this way, they were able to test the performance of the labels in a variety of settings, increasing the likelihood they could roll the new labels out system wide and have a greater impact.

From comments about ease of use and visibility to the direct impact they have on patient safety, Shamrock’s custom IV labeling solution for Sutter Health was met with resounding approval by the staff at SMCS and Sutter David Hospital ICUs. Geary attributes this to her guiding principle throughout the project: “Make the right thing to do the easy thing to do.”

“I think this is extremely pertinent to healthcare,” she said. “The harder we make things, the less often they are done or are done correctly. Medication
administration is such a high risk process, that anything we can do to make it easier for the nurse to perform safely, the better.”

So, What Is Your Labeling Need?

With over 50 years of experience in healthcare labeling and variety of stock and custom options available, we can help you find the right solution. Start creating now or call us at (800) 323-0249.

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