Intravenous therapy device labeling in Intensive Care Units: an integrative review.
Geovane de Kassio Nunes, Juliana Faria Campos, Rafael Celestino da Silva
PMID 36197432WHAT IT FOUND
ICU teams often miss or incompletely label IV lines, syringes and bags.
Pre-designed color-coded labels, used with infusion organizers and careful line tracing, help identify infusions, but practice is not standardized.
Key findings
01In one neonatal ICU observation, 65.7% of 70 prepared IV medication doses had no label, and among labeled doses only 11.4% were complete.
02In one Canadian ICU study, incomplete labeling of IV lines was 31.5% of 5,641 errors and incorrect labeling was 26.8%.
03IV-line labels and infusion organizers may increase accuracy in correctly identifying infusions in one simulation, and color-coded labels improved identification of bags, but color-coding syringes did not show a significant difference in one comparison.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
This is a review of 11 articles, not a new trial, so it cannot prove that labeling reduces medication errors. The included studies used different designs and outcomes, so the review grouped them into synthesis units rather than pooling numbers. The ISO 26825 standard was aimed at anesthesia and syringes, and extending it to ICU devices is not validated by regulatory agencies. Authors noted that some studies lacked detail about the characteristics of the labels used. This limited deeper analysis. The search included full-text articles from 2008 to 2021 in English, Portuguese or Spanish, so relevant studies outside those limits may be missing. Low compliance and variability mean the evidence describes practice gaps, not a validated universal labeling standard.
The easy way to misread this
Do not conclude that labeling alone prevents IV medication errors. The review found labeling helps identification, but one simulated syringe-color task did not improve performance compared with control, and a correctly prepared medication can still be mislabeled or unlabeled and cause harm.