By Peggy McDaniel, BSN, RN

There has been a recent push by some manufacturers to promote color coding for product identification. Of course, even with the best intentions, these color-coded products have not reduced the incidence of medical errors and may actually promote errors.

The February Nurse Advise newsletter from the Institute for Safe Medication Practices (ISMP) (click here to subscribe to the newsletter) reports a medication error in which a nurse injected oral medication from an oral syringe into a Bard PowerPICC (percutaneously inserted central catheter). The PICC line is manufactured in a purple color and may have been confused with an enteral feeding system from Covidien, which is the same shade of purple. Even though the nurse was using an oral syringe, she was able to hold it up tightly enough to the open female luer of the PICC tubing to inject the oral medication intravenously. This error highlights both a “misconnection” and a color-coding confusion.

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