SAFE MEDICATION PRACTICES

Standardizing the Storage and Labelling

of Medications: Part 1
Jonas Shultz, Margot Harvie, Dawn McDonald, Jim Manley, and Mollie Cole

Contributions to this column are prepared by the Institute for Safe Medication Practices
Canada, a key partner in the Canadian Medication Incident Reporting and Prevention
System (CMIRPS). From time to time, ISMP Canada invites others to share learning based
on local initiatives.

BACKGROUND medication storage areas and the legibility of labels. The

initial aim was to make recommendations that could be

S everal health care studies have examined the

frequency of preventable adverse drug events. The
Institute of Medicine has estimated that on average at
achieved quickly, beyond the benefits associated with
computerization and automation. The specific goals of this
initiative are as follows:
least one medication is given in error to each hospital
• to improve patient safety by decreasing preventable
patient per day.1 Other statistics suggest that the
adverse drug events
administration of up to one in every five medications is
• to reduce variability in the way medications are stored
associated with some type of error.2,3 These errors
throughout the region
include administering the wrong drug or the wrong
• to increase efficiency
dose, or administering an intended drug at the wrong
As part of the Calgary Health Region’s enhanced
time or by the wrong route. Similarities between
medication names (i.e., look-alike and sound-alike patient safety strategy,8 new storage and labelling
names) and labels (i.e., look-alike packaging), as well as guidelines have been developed in response to learning
unsafe storage practices, have been cited as contributory from specific preventable adverse drug events such as
factors,4,5 some of which have resulted in death.6 In an those highlighted in the Alberta Medication Safety
effort to learn from and address such medication safety Collaborative Opioids (Narcotics) Project (a collaborative
issues, the Calgary Health Region has begun an initiative medication safety initiative of ISMP Canada, the Health
to standardize and simplify the storage and labelling of Quality Council of Alberta, and the Alberta Regional
medications. Labelling improvements will be the focus of Pharmacy Directors) and those involving deaths related to
a subsequent article. This article highlights the enhance- potassium chloride.9,10 The storage and labelling guidelines
ments that are being made in the storage of medications. in the Calgary Health Region apply human factors
The Calgary Health Region’s medication storage principles of display design11 and are based on findings
initiative is being applied to more than 500 areas where obtained in a regional quality improvement initiative, the
medications are stored. These areas include inpatient 2004/05 Patient Safety Collaborative for Medication.
pharmacies, patient care units, and outpatient clinics in a The following issues of concern were identified with
region that is made up of more than 100 facilities, including medication storage:
12 acute care sites, 40 care centres, and a variety of • Multiple medications or multiple doses of a single
community and continuing care sites, all of which serve a medication were stored in one storage bin without a
population of 1.1 million people.7 This medication safety divider, which increased the likelihood of selecting the
initiative specifically targets the functionality of the wrong medication.

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 • Medications were stored in unlabelled and open bins,
which meant that individual health care practitioners
often selected medications on the basis of visual
properties of the medication and its packaging (e.g.,
size, colour). Look-alike packages may be particularly
problematic in this situation. Contributing to the error
potential was the fact that practitioners were some-
times unaware of a change in medication supplier(s)
or changes to the appearance of product packaging
made by suppliers.
• Excess quantities of certain medications were being
stored, which increased the likelihood that medications
would spill into adjacent bins; this also increased the
number of expiration dates that needed to be Figure 1. Medication storage area before (left) and after (right)
implementation of changes. The new system uses red, yellow,
checked. and green bins to store injectable, oral, and topical medications,
• Inconsistencies in the way medications were stored respectively.
within and between patient care areas forced health
care workers to learn a variety of storage schemas.

SAFETY ENHANCEMENTS
Medication Storage Areas
• Standardization: The medication storage format was
simplified and standardized for all areas in an effort to
enhance consistency and efficiency. This standardization
allows individual health care workers to learn how
medications are organized in one area and to use that
knowledge to find medications when working in
different areas. This is particularly important for those
who regularly work in several areas, for example, on
one or more patient care units.
• Clustering: Medications have been “clustered” into
logical groups (i.e., injectable, oral, and topical med- Figure 2. Multiple medications stored in one bin, with divider labels,
ications) in an effort to minimize choice and simplify including the number of units to be maintained in each section.
searching for a specific medication. For example, a
nurse who is looking for a tablet of acetaminophen
can easily eliminate all injectable and topical divider label (Figure 2) includes the name of the
medications from his/her search (see Figure 1). medication, the dosage form, the strength and the
• Use of colour: Coloured bins have been used to package size, and the number of items in each section.
provide visual redundancy, which helps in distin- (Additional information on labelling will be provided
guishing among the clustered medication groups.12 For in the subsequent article.)
example, red, yellow, and green bins are used to store • Separate: Narcotic storage bins were redesigned to
injectable, oral, and topical medications, respectively. separate narcotics according to the duration of action,
i.e., short-acting and long-acting. Further differentiation
Medication Bins was provided by adding a label to the applicable
storage bins stating “LONG ACTING”, similar to that
• Minimize: To reduce the opportunity for confusion,
applied to the narcotic package itself.
the number of medications and concentrations of the
same medication stored in one bin has been
CONCLUSIONS
minimized. When multiple medications or concen-
trations of the same medication have to be stored in Completion of this medication safety initiative in the
the same storage bin, a labelled divider is used. The Calgary Health Region’s patient care areas is expected

124 C J H P – Vol. 60, No. 2 – April 2007 J C P H – Vol. 60, no 2 – avril 2007
by fall of 2007. A formal evaluation of the storage 8. Flemons WW, Eagle CJ, Davis JC. Developing a comprehensive
patient safety strategy for an integrated Canadian healthcare
and labelling guidelines is currently in progress. This
region. Healthc Q 2005;8(Spec No):122-127.
assessment will examine the usability of the guidelines
9. Concentrated potassium chloride: a recurring danger. ISMP Can
through such measures as the time spent in stocking and Saf Bull 2004;4(3):1-2.
selecting medications, the number of medications placed 10. Johnson RV, Boiteau P, Charlesbois K, Long S, U D. Responding
in the wrong bin, and label visibility and legibility. to tragic error: lessons from Foothills Medical Centre. CMAJ
2004;170(11):1659-1660.
Ongoing overall surveillance of preventable adverse drug
11. Wickens CD, Lee J, Lui Y, Gorden-Becker S. An introduction
events will continue to drive patient safety improvements.
to human factors engineering. 2nd ed. Upper Saddle River (NJ):
Although the impossibility of completely eliminating all Pearson Education; 2004.
preventable adverse drug events is acknowledged, the 12. Department of Defense design criteria standard: human engineering.
primary goal of this initiative is to enhance patient safety US Department of Defense; 1999 [cited 2005 Oct 11].
MIL-STD-1472F. Available from: http://hfetag.dtic.mil/docs-hfs/
by reducing the overall probability of an incorrect drug
mil-std-1472f.pdf
selection.
Look for “Standardizing the Storage and Labelling of
Medications: Part II”, which will discuss the labelling
component of this initiative, in the June 2007 Safe Medica-
tion Practices column.
Jonas Shultz, BA(Hons), MSc, is a Human Factors Consultant, Calgary
References Health Region, Calgary, Alberta.
1. Aspden P, Wolcott JA, Bootman JL, Cronenwelt LR. Preventing Margot Harvie, RN, BN, is the Initiative Specialist for Medication Safety,
medication errors. Washington (DC): National Academic Press; Calgary Health Region, Calgary, Alberta.
2007. Quality Chasm Series.
Dawn McDonald, BSP, ACPR, is the Drug Therapy Management
2. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication Pharmacist, Calgary Health Region, Calgary, Alberta.
errors observed in 36 health care facilities. Arch Intern Med
Jim Manley, BPE, is the Pharmacy Technical Manager, Calgary Health
2002;162(16):1897-1903.
Region, Calgary, Alberta.
3. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G.
Medication errors and adverse drug events in an intensive care Mollie Cole, RN, MN, GNC(C), is a Nurse Consultant for Professional
unit: direct observation approach for detection. Crit Care Med Practice and Development, Calgary Health Region, Calgary, Alberta.
2006;24(2):415-425. e-mail: [email protected]
4. Cohen MR. Drug product characteristics that foster drug-use- ISMP Canada homepage: http://www.ismp-canada.org
system errors. Am J Health Syst Pharm 1995;52(4):395-399.
Acknowledgements
5. Lambert BL. Predicting look-alike and sound-alike medication
The authors greatly appreciate the review of this paper by Drs Jeff Caird
errors. Am J Health Syst Pharm 1997;54(10):1161-1171.
and Jan Davies, University of Calgary, as well as other employees of the
6. Paralyzed by mistake. Preventing errors with neuromuscular Calgary Health Region, including Steve Long (Director of Pharmacy),
blocking agents. ISMP Med Saf Alert 2005;10(19):1-3. Janice Harvie (Communication Advisor), the Pharmacy Clinical
7. Millar C, Vanderburg G, Bullick T, O’Meara D, Sankey D. Committee, and the staff who tested the guidelines.
Leading the way. Calgary Health Region report to the community. ISMP Canada gratefully acknowledges the valuable learning that is
Calgary (AB): Calgary Health Region; 2005 [cited 2006 Dec 29]. gained from information reported by professionals in the Canadian health
Available from: http://www.calgaryhealthregion.ca/communica- care community, which can then be shared to enhance medication
tions/pdf/ 2005_report_to_the_community.pdf system safety.

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