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Medication Labels /
JCAHO
JCAHO Medication Label Requirements
Requirement 3D
Label all medications, medication containers (for example, syringes, medicine
cups, basins), or other solutions on and off the sterile field.
Rationale for Requirement 3D
This risk reduction activity is consistent with safe medication practices
and addresses a recognized risk point in the safe administration of medications
in perioperative settings.
Errors, sometimes tragic, have resulted from medications and other solutions
removed from their original containers and placed into unlabeled containers.
Medications or other solutions in unlabeled containers are unidentifiable.
This unsafe practice neglects basic principles of medication management safety
yet has been routine in many organizations with respect to medications
transferred to the sterile field.
Implementation Expectations for Requirement 3D
A 1. Medications and solutions both on and off the sterile field are labeled
even if there is only one medication being used.
A 2. Labeling occurs when any medication or solution is transferred from
the original packaging to another container.
A 3. Labels include the drug name, strength, amount (if not apparent from
the container), expiration date when not used within 24 hours, and expiration
time when expiration occurs in less than 24 hours.
C 4. All labels are verified both verbally and visually by two qualified
individuals when the person preparing the medication is not the person
administering the medication.
A 5. No more than one medication or solution is labeled at one time.
A 6. Any medications or solutions found unlabeled are immediately discarded.
C 7. All original containers from medications or solutions remain available
for reference in the perioperative area until the conclusion of the procedure.
A 8. All labeled containers on the sterile field are discarded at the conclusion
of the procedure.
C 9. At shift change or break relief, all medications and solutions both
on and off the sterile field and their labels are reviewed by entering and
exiting personnel.
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