Two Syringes, One Label

In practice

During a breast procedure, the surgeon plans to inject a local anesthetic into the wound at the end of the case. Early on, the circulating nurse transfers the local anesthetic to the field, and the scrub person, Jordan, draws it into a syringe. At the same moment, the surgeon asks for saline to irrigate a small area, and Jordan fills a second syringe of the same size with saline. Both syringes now hold clear fluid. Jordan has a label ready for the first syringe but is interrupted by a request for a clamp, and both syringes end up side by side on the Mayo stand, one labelled and one not. Forty minutes later, the surgeon asks for the local. Jordan reaches for the syringes and stops. One is labelled; the other is not. Jordan believes the labelled one is the local anesthetic, but cannot be certain the labels were not swapped in the rush, and cannot know the contents of the unlabelled one by looking. Jordan says so aloud, discards both, and asks the circulating nurse for a fresh transfer of the local anesthetic, which is drawn up and labelled at once. The delay is two minutes. After the case, the team talks about it at the debrief, and Jordan's practice changes: from now on, every syringe is labelled at the moment it is filled, before any other request is answered.