IV SOLUTION AND DRUG LABELING POLICY

1. Label all IV medication infusions with the patient's name, date, and time hung.  It is desirable to use the patient's addressograph stamp label to identify the patient.  Additionally, include on our standard solution label (yellow label - see below) with all drug additives, amount (dose), date/time prepared and/or started, and your initials.
2. If you are going to take buretrols or syringes containing medications outside the operating room with an intent for someone else to continue using them, label with all the elements as described in #1 above.  Syringes for use only in the operating room need only be labeled according to standard OR  policy with the medication's name and concentration (propofol also requires the time the syringe was made).
3.  Drugs administered by Medfusion pumps must be labeled on the syringe with the drug's name and concentration.  If you plan to take the infusion pump outside the OR and continue using it in the PACU or the ICU, then labeling requirements in #1 apply here also.

A:   Solution must be labeled with the patient's name and medical record number.  If you also use an addressograph label, you do not have to repeat the information here.  Put the OR number where you are located in the "Room" field.

B:  Enter today's date, including at least the month and the day.

C:  Enter the time the solution was mixed.  This is important as different solutions expire in different time periods.

D:  Your initials should be entered in this place.  The initials plus the OR# should be enough to adequately identify who made the solution should any questions come up later.

E:   The time the solution was first used should also be entered.  If you draw out a syringe from the solution to use for bolus administration, you should enter that time as the time started.

F:  Date started:  In all cases in the OR, the date started should be the same as the date mixed.

G:  Enter the generic OR the trade name of the drug - please be legible.

H:  Enter the AMOUNT of drug added to the solution.  DO NOT ENTER THE SOLUTION CONCENTRATION THAT YOU CALCULATED.  If you make a calculation error, this error would then continue with all future practitioners.  If you enter the amount of drug added, all future health care providers may calculate the drug concentration for themselves.

Flow rate, expiration date and base solution do not need to be entered.  The expiration date can be determined from the time the solution was made and the base solution is clearly already labeled on the IV bag.  It is desirable, but not required, that you enter the infusion rate needed for the lowest commonly used dose (e.g. for Sodium nitroprusside - 8 cc/hr = 1ug/kg/min).

Please note that ALL IV MEDICATION INFUSIONS UTILIZED IN THE OPERATING ROOM OR LEAVING THE OPERATING ROOM GOING TO THE PACU OR AN ICU MUST BE LABELED ACCORDING TO THIS POLICY.  Housestaff, CRNAs or faculty failing to follow this policy will receive an administrative letter after the first violation.  Housestaff who repeatedly violate this policy will receive administrative sanctions up to and including probation.  CRNAs or faculty who repeatedly violate this policy will be counseled by the chairman.  Because we have done so poorly with this policy in the past, audits will be conducted frequently until compliance improves.