Best Practices for Labeling of Intravenous Lines for Patients with Multiple Simultaneous Infusions

Institute for Safe Medication Practices (ISMP)
Huntingdon Valley, Pennsylvania, USA


A nurse recently asked the Institute for Safe Medication Practices (ISMP) for advice about the use of color coding intravenous (IV) lines:


Q: We are looking for best practices for labeling IV lines for patients who have multiple simultaneous infusions. Some have suggested color coding the labels for each drug — for example, blue = magnesium, red = potassium, etc. It is my understanding that this is a practice that is no longer advised because practitioners rely on the color of the label versus reading the label to verify the correct medication. Does the ISMP have a recommendation on this topic? 


The response, written by Michael R. Cohen, RPh, MS, DSc, President of the Institute for Safe Medication Practices is a useful synopsis of the issues involved in color coding: 


A: To begin with, I’d like to emphasize the difference between color coding, color differentiation, and user-applied versus commercially-applied color cues. I define color coding as a systematic application of color to identify specific products. For example, black caps are currently a code in the United States for potassium chloride concentrate injection. No other product is allowed to have this color. If you see a black cap on a drug vial, you can bet that it is potassium chloride throughout the United States (unless some old vials with black caps — long expired — are stashed away somewhere). Color differentiation entails use of color to make certain features stand out or to help with identifying items, but the color itself has no specific meaning (it's not a code for something) and is not necessarily applied in the same consistent way as it is with color coding.


As far as I can tell, neither color coding nor color differentiation systems are scientifically tested as a way to prevent errors and, like anything else, they may actually cause some errors that would not otherwise happen without these systems. For example, we've run articles now and then about commercial color code schemes for ophthalmic products where color is assigned as an indicator of pharmacological category. Unfortunately, there are frequent dispensing errors within the categories and patients receive the wrong drug (see photo below as an example).

The ophthalmologists love the system but pharmacists and nurses, especially those who've made dispensing errors, hate it. Another example is color coding of disposable syringes by needle gauge. We've had quite a few tenfold overdoses of insulin because the 26G needle on some tuberculin syringes is now orange (recent change), as is the color assigned to insulin syringes. We've also observed occasional problems with user-applied color coded labels in anesthesia. Although when properly applied the color of the label identifies a drug category, the scheme does not necessarily identify a specific drug. Therefore, anyone other than the person who prepared the syringe may be in danger of using the wrong drug if they rely on color without reading the label. Also, it's been my observation that these labels often are used without recording the amount of drug contained within (I've seen this many times on our hospital visits to the OR). Of course, that said, I would not argue with you about the value of color coding schemes in anesthesia where the system is used as intended.
There are a number of problems that prevent health care from adopting color coding systems to identify pharmaceuticals (so that all companies would use the same schemes), not the least of which is that there is a limit to how many colors are available for commercial use. But there are other significant problems that I've learned over the years in dealing with folks from the pharmaceutical industry and the United States Food and Drug Administration (which frowns on color coding for the most part).
Color differentiation is another story. Depending on how it is applied commercially, it can be an aid to reducing errors and I've recommended it many times for commercial use. But there must be consistent patterns that people can rely upon (which may be difficult to assure in user-applied situations). If a company uses yellow and blue labeling for 80 percent of their 10 mL vial drug labels and color differentiation for the remaining 20 percent, users are more likely, on a quick scan, to believe that the yellow and blue vials on 10 mL containers must all be the same drug. We saw many errors when Novation was doing this with their parenteral drug vial line. Color differentiation by the pharmaceutical industry is not done across companies, which is a frequent factor that leads to mix-ups between different drugs from different manufacturers in look-alike containers.
It is far more likely that people will read the print on the label if all labels are consistently black and white. We saw this with Baxter ATC 212 dispensing machines. All 212 drugs were dispensed in unit-dose packages with a black and white label. This has been consistent over many years. Nurses soon came to know that the only way to differentiate a product was to actually read the label and over the years we did not have reports of medication errors.
Let's also not forget other factors such as large type, use of logos and label designs, etc., that can also add or detract from product identification, even with judicious use of color.
Color can also enhance recognition of various label elements. For example, if the entire label is black and white except for a red printed warning, it's very likely that the warning will be recognized more easily than if it was also printed in black and white.
As for the issue of user-applied labels for IV lines by many different individuals, there is not much to guide us scientifically and I am not sure on which side the balance would rest. It is difficult to standardize user-applied labeling of IV lines, especially when more than a few individuals are involved. To begin with, not everyone will even use it. Some will apply labels on the wrong IV line (they could do this with black and white labels too of course, just as we have people adjusting the wrong infusion pump, piggyback line or gravity flow control clamp). But there will also be some folks on the nursing unit who mistakenly identify the color or who are not familiar with the system. The bottom line is that if you are going to add labels onto the IV line at all, this has to be done along with an educational campaign so users properly trace the IV lines and apply the labels. But there is also no research to guide us either way.
Read a similar feature on color coding published in the ISMP newsletter.
The Institute for Safe Medication Practices (ISMP) newsletter reprinted with permission from ISMP.
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