Recently we had a mix up of a nitroprusside drip bag being labeled with the UPC and label that is appropriate for neosynephrine. The patient's pressure started dropping and thankfully the RN thought to peel back the label on the bag and saw that it was actually having the opposite effect.
Our hospital's stance on labeling meds is that they want all the same font, color etc because otherwise people will start to rely on the color system and then if things changes more mistakes will happen. This makes sense to me but it's frustrating that people regulating this system have no idea what it's like to have that gut wrenching feeling when a patient is in danger and under your care - whether or not you caused it.
We only have one high risk med that is labeled huge and has a neon sticker and I wonder what it took to get that one pushed through. What does your unit do with labeling high risk meds like pressors, insulin, nitro etc? Not that this would have helped in this situation but I was curious.