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In Response

Grigg, Eliot B. MD; Martin, Lizabeth D. MD; Roesler, Axel PhD

doi: 10.1213/ANE.0000000000002355
Letters to the Editor: Letter to the Editor

Published ahead of print August 4, 2017.

Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, Seattle Children’s Hospital, Seattle, Washington,

Division of Design, School of Art + Art History + Design, University of Washington, Seattle, Washington

Published ahead of print August 4, 2017.

Dr Roth1 makes an excellent point about the importance of labeling to identify syringes. The most specific clue to the contents of a syringe (if accurately applied) is the text contained within the label. Mechanisms to help that information register cognitively are beneficial including label orientation, font size and style, text color and contrast, and Tall Man lettering. At Seattle Children’s Hospital—and for the purpose of the study in question—it is standard practice to apply both longitudinal and circumferential labels. A few of the syringes (typically emergency medications) are prefilled by compounding organizations and include circumferential labels with vertically and horizontally oriented text, color coding, and Tall Man lettering.

However, despite its specific nature, even textual information is not 100% reliable in a stressful or repetitive environment. The human mind is designed to create mental shortcuts; it is an adaptive trait to help filter the millions of bits of data that the visual system processes every second.2 As a result, it is possible that any individual clue to a syringe’s identity—including location and color—could exacerbate mental shortcuts. Concern has been expressed in the past, for example, that color coding of syringes may contribute to syringe swaps within drug classes if it discourages providers from scrutinizing labels more closely. In response, some have suggested that removing additional identifiers might force users to read labels more carefully, but we believe this is an unrealistic and potentially dangerous solution.

Multiple sources in the design literature suggest that the most robust way to identify targets (in this case syringes) is to use multiple indicators in tandem.3 Location, color, size, and shape are all important visual cues in addition to textual information. Better yet, engaging other senses like touch and hearing can improve target identification. This is why an oxygen flowmeter knob might have a specific texture, or a bar-code reading system might speak a medication name. Ultimately, any design solution must be specific to the problem space in question, and for anesthesia medication identification, a suite of solutions including robust labeling, standardized layouts, and information system integration will need to work together to minimize medication errors.

Eliot B. Grigg, MDLizabeth D. Martin, MDDepartment of Anesthesiology and Pain MedicineUniversity of WashingtonSeattle, WASeattle Children’s HospitalSeattle,

Axel Roesler, PhDDivision of DesignSchool of Art + Art History + DesignUniversity of WashingtonSeattle, Washington

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1. Roth JV. The placement of syringe labels may reduce medication errors and cognitive load. Anesth Analg. 2017;125:1421–1422.
2. Koch K, McLean J, Segev R, et al. How much the eye tells the brain. Curr Biol. 2006;16:1428–1434.
3. Ware C. Information Visualization: Perception for Design. 2013.3rd ed. Waltham, MA: Morgan Kaufmann.
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