As of May 1, 2017, this administrative policy applies to the operations and staff of legacy UWHC. Effective July 1,
2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of Wisconsin
Hospitals and Clinics Authority (UWHCA). All administrative policies are being transitioned to apply UWHCA-wide,
but until future revision to this policy #7.80, it applies only to the operations and staff of legacy UWHC.
7.80 Medication, Medication Container and Solution Labeling
UWHC Administrative Policy
May 1, 2017
Patient Support (Hospital Administrative)
Labeling medications, containers and solutions is a basic principle of safe medication management. In an effort to
reduce the potential for medication errors, this policy provides a process for labeling medications, medication
containers and/or other solutions.
A. Any time one or more medications are prepared but not administered immediately, or anytime the person
preparing the medication is not the person administering the medication, the medication’s container must
be appropriately labeled. Medication containers include syringes, medicine cups, and basins.
B. All medication containers must be labeled even if there is only one medication being used, except those
which are drawn for use and used immediately by the person who drew it up.
A. Medications include any prescription medications; herbal remedies; vitamins; nutraceuticals; medical
foods; over-the-counter drugs; vaccines; diagnostic and contrast agents used on or administered to
persons to diagnose, treat or prevent disease or other abnormal conditions; radioactive medications;
respiratory therapy treatments; parenteral nutrition; pharmacy-dispensed blood derivatives; intravenous
solutions; and any product designated by the Food and Drug Administration (FDA) as a drug.
B. Henceforth items listed in III.A. above will be referred to as "medications".
A. Label medications, medication containers and solutions that are not immediately administered to a
patient. This applies even if there is only one medication being used. An immediately administered
medication is one that a staff member personally prepares, takes directly to the patient, and administers
to that patient without any break in the process.
1. The medication, medication container or solution must be labeled if:
a. The medication or solution is transferred from the original packaging to another
b. The medication is prepared and slowly administered over the course of a procedure;
c. The medication is prepared by a staff member other than the administering provider;
d. The medication is prepared in bulk for the day's cases;
e. The provider preparing the medication participates in another function prior to
B. The labels are verified both verbally and visually by two individuals (at least one must be a licensed or
certified professional) when the person preparing the medication is not the person administering it to the
C. Appropriate labeling consists of:
1. Name and concentration (strength) of the medication or solution.
2. Volume/amount (if not apparent from the container).
3. Diluent name and volume (if not apparent from the container).
4. Expiration date (if it is not to be used within 24 hours).
5. Time of expiration (if it is less than 24 hours).
D. All prepared medications and solutions without an expiration date will be discarded if not used at the end
of the procedure or the end of the day.
1. Labels should be removed from containers before sending to reprocessing, where applicable.
2. All labeled containers on the sterile field that are not sent for reprocessing are discarded at the
conclusion of the procedure.
E. An individual should not label more than one medication container at a time
F. All original containers from medications or solutions need to remain available for reference until the
conclusion of the procedure.
G. At shift change or break, all medications and solutions and their labels are reviewed by entering and
exiting personnel using a standardized method of hand-off communication.
H. Any medications or solutions found unlabeled are immediately discarded.
I. In an emergency where time does not allow for labeling, the person preparing the drug should verbalize to
the person administering the drug the contents of the prepared medication container prior to
V. RELATED POLICIES
Administration of Medications, Hospital Administrative Policy #8.17
The Joint Commission 2017 National Patient Safety Goals, NPSG.03.04.01
Sponsor: SVP/Chief Admin Officer
Author: Pharmacy Coordinator, Regulatory Compliance
Review/Approval Committee(s): Medication Safety Officer; Director, Surgical Services, Medication Safety
Committee; UW Health Clinical Policy Committee; Medical Board
Peter Newcomer, MD
Chief Clinical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee