The medical malpractice lawsuit involving a 69-year-old woman who died last fall after she received an injection from an unlabeled container of the antiseptic chlorhexidine rather than radiological dye highlights the need for proper medication labeling in all procedure areas, experts say.

The lawsuit stems from the death of Mary McClinton last fall at Virginia Mason Medical Center in Seattle. Ms. McClinton died 19 days after the injection mixup during a procedure to fix a damaged blood vessel.

Virginia Mason has apologized publicly and admitted liability for Ms. McClinton's death. As part of a legal settlement with Ms. McClinton's family, Virginia Mason will use her case to help teach medical staffers the importance of proper labeling of medications.

Facilities are required to label all medications, medication containers (syringes, medicine cups and basins, for example), or other solutions on and off the sterile field in perioperative and other procedural settings, according to JCAHO's 2006 National Patient Safety Goal 3D.

"Any medication that is put down in the surgical field or is not intended for immediate use should be labeled," says Sheldon Sones, RPh, FASCP, president of Sheldon Sones and Associates, a pharmaceutical consulting firm in Newington, Conn. "That goes for potent medications as well as those that might be considered more innocuous."