Practice variability with syringe labelling practices among anaesthesia residents

Practice variability is associated with human error and adverse drug events. We sought to describe the practice variability that exists with drug labelling among a cohort of anaesthesia residents in an academic medical centre.

In a controlled, lecture-style environment, residents were instructed to prepare a syringe of atracurium. Label location (longitudinal vs. circumferential), orientation (right hand vs. left hand), compliance, and legibility were assessed.

A total of 32 syringes with 48 labels were analysed, of which 11 (34%) had a single longitudinally placed label, 6 (19%) had a single circumferential label, and 15 (47%) had both longitudinally and circumferentially placed labels. Of syringes with longitudinally placed labels, 17 (63%) were placed in the right-hand orientation, 9 (33%) in the left-hand orientation, and 1 (4%) had 2 labels placed in both orientations. Of the syringes with circumferentially placed labels, 17 (81%) were placed in the right-hand orientation and 4 (19%) in the left-hand orientation. Overall compliance with longitudinal and circumferential labels was 95.6% and 43.8%, respectively. Overall legibility with longitudinal and circumferential labels was 90.7% and 90.5%, respectively.

A great deal of practice variability with syringe labelling among anaesthesia residents was observed, with significant non-compliance of circumferentially placed labels, which could play a role in increasing the risk of drug errors.