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Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety
  1. N Porat1,
  2. Y Bitan1,2,
  3. D Shefi1,
  4. Y Donchin1,
  5. H Rozenbaum1
  1. 1
    Hadassah University Medical Center, Jerusalem, Israel
  2. 2
    The Cognitive Technologies Laboratory, University of Chicago, Chicago, Illinois, USA
  1. Correspondence to Nurit Porat, Hadassah University Medical Center, Ein Kerem, PO Box 12000, Jerusalem 91120, Israel; nuritp{at}


Problem: Labelling of high-risk drug infusions and lines is a well-recognised safety strategy to prevent medication errors. Although hospital wards characterised by multiple high-risk drug infusions use different types of labelling, little is known about the contribution of a colour-coded label (CCL) to patient safety.

Setting: A quality improvement programme audit at a tertiary care facility, the Hadassah University Medical Center Ein Kerem, Jerusalem, Israel.

Strategy for change: A CCL for intravenous (IV) high-risk medications and lines was designed to promote safer medication administration at the intensive care unit bedside and in other acute wards.

Methods: The purpose of the study was to compare a new CCL method (intervention) with the current labelling method (control). Laboratory simulation, imitating an intensive care unit, was designed. Safety of the medication treatment and overall duration of nurses’ orientation with drugs and lines at the patient’s bedside were measured.

Effects of change: The use of the new CCL improved proper identification of IV bags (p<0.0001), reduced the time required for description of overall drugs and lines (p = 0.04), improved identification of errors at the treatment setting—drugs and lines (p = 0.03) and reduced the average performance time for overall tasks (p<0.0001).

Lessons learnt: The use of CCLs for IV high-risk medications and lines can improve patient safety and improve medical staff efficiency.

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  • Competing interests None.