Color Coded Clarity

Author: Hashim Zaidi, MD (EM Resident Physician, PGY-1, NUEM) // Edited by: Michael Macias, MD (EM Resident Physician, PGY-3, NUEM) // Expert Reviewer: Abra Fant, MD

Citation: [Peer-Reviewed, Web Publication] Zaidi H, Macias M (2016, March 22). Color Coded Clarity. [NUEM Blog. Expert Peer Review by Fant A]. Retrieved from http://www.nuemblog.com/blog/color-coded-clarity

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Introduction

With almost 400,000 drug-related injuries occurring each year in US hospitals, medical errors continue to increase at an alarming rate with significant morbidity and mortality [1]. While rates of medication error vary depending on the detection method, for patients in the hospital setting, it is estimated that one medication error happens at least once a day [2]. The American Academy of Ophthalmology (AAO) has been attempting to reduce errors in ophthalmic drops since the mid-90’s with the advocacy of a uniform color coded system for topical ocular medications. This standardized color system would then theoretically help patients and providers identify medications correctly and reduce errors both inpatient and outpatient.

Citing the high degree of “look alike sound alike” medications in topical ocular medications, the AAO worked in conjunction with the FDA and pharmaceutical industry executives to develop industry recommendations for drug classes and color codes detailed below:

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Key Color Coded Medications For the Emergency Provider

Tan indicates antimicrobials/anti-infectives which may include antifungals, antivirals, or antibacterials.

Pink topped medications indicates steroids which if misused or confused by patients can lead to bacterial, viral or fungal infections, delayed healing or cataract development.

Red is utilized for mydriatics and cycloplegics utilized to dilate the pupil and examine the posterior eye segment.

Yellow and Dark Blue indicate beta blockers commonly used to reduce intraocular pressure and treat glaucoma.

Turquoise colored tops are prostaglandin analogs also commonly used to facilitate aqueous humor drainage and decrease intraocular pressure.

Several Topical Eye Medications [3]

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Working with pharmaceutical companies to adopt the standardized system is still an ongoing issue with the FDA and AAO. Challenges still exist in several sectors to establish a universally adopted system. In the picture above we see three out of four bottles appropriately color marked except for the tobramycin, which should be tan for its antimicrobial properties. Provider education also continued to be a hurdle. A recent article in Ophthalmology revealed that most providers were still unfamiliar with the color system and their understanding of the medication from cap color was often incorrect [4]. While the color coding system appears overall beneficial, especially in an office setting or in a patient’s home, a review from 2011 stressed concern about color coded caps creating a potential for iatrogenic harm secondary to confusion between topical medications in the same class [5].

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Take Home Points:

• With proper education of the color coded system, an appropriate understanding of which ophthalmological medications a patient utilizes can be gained, helping the emergency physician obtain a better grasp of their current presentation and prevent iatrogenic harm.

• The color coded system is not foolproof and a potential for error in medication administration still exists, therefore good clinical judgement and familiarity with the active ingredient in each topical medication should still be maintained.

• For the complete list of color codes and classes of topical ocular medications, check out the policy statement from the American Academy of Ophthalmology.

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Expert Review

Thank you for your post.

Medication errors are indeed one of the greatest sources of error within the modern medical system and can cause significant morbidity and even mortality. Many strategies exist to help providers to properly identify and administer the correct medication at the correct dosage to the correct patient, however none of these are foolproof. Some strategies are:

Tall man lettering in look-alike, sound-alike medications to highlight the differences in medication names to reduce error.

Specific storage of certain high risk medications.

Color coding to help providers identify medications by class. 

Color-coding has been utilized in chemotherapeutic agents as well as eye drops. It is also being proposed for tubing and line connections. However, there is no standardized color-coding system and practices vary between color matching (blue tubes connect to blue tubes) and color differentiation (yellow for oral medications and red for IV medications). Given the lack of standardization, all of these schemes require a significant educational effort in order to be successful. A national standard may help with this educational hurdle, but little data yet exists to suggest the effectiveness of the color-coding approach in reducing medication errors.

Abra Fant , MD, MS

Medical Education Fellow; Instructor; Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine

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References

1. FDA Guidance for Industry: Safety Considerations for Product Design to Minimize Medication Errors;” Food and Drug Administration: Drug Safety December 2012

2. Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care.2006;17(2):86–94.

3. https://www.optometrystudents.com/write-prescription-quick-reference-guide Accessed 30 August 2018

4. Dave P, Villarreal G, Friedman DS, Kahook MY, Ramulu PY. Ability of Bottle Cap Color to Facilitate Accurate Patient-Physician Communication Regarding Medication Identity in Patients with Glaucoma. Ophthalmology. 2015;122(12):2373-9.

5. Grissinger et al 2011 “Ambulatory Surgery Facilities: A Comprehensive Review of Medication Error Reports in Pennsylvania“ Vol 8, No3 Sept 2011 Pennsylvania Patient Safe

6. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.