Learn about medication practice changes for multi-dose vial labeling, vaccine documentation and transdermal medication patches.

What’s happening? 

The Medication Practice: Medication Prescribing, Directive/Order Processing, Administration and Documentation – Clinical Protocol was recently revised to reflect the latest Accreditation Canada’s Medication Management required high priority standards. This revision is associated with some practice changes to multi-dose vial labeling, vaccine documentation, and transdermal medication patch labeling.

Why is this important? 

Multi-dose vial labeling: Multi-dose vials should be used for a single patient and labelled with a beyond-use data label. Single-dose vials do not contain preservatives and should be discarded after use to reduce the risk of cross-contamination and spread of blood born infection among patients.

Vaccine documentation requirements: Documentation of brand name, lot number, expiry date, and body site is the right thing to do to achieve the best results for patients, residents, and clients. It facilitates a track back in cases of a patient safety event, or product concern.

Transdermal medication patches: A transdermal patch is designed to provide consistent and continuous drug delivery through the skin into the bloodstream. Regular confirmation of patch adhesion and position is essential for effective response to medication.

How will this impact students and faculty instructors? 

  • Multi-dose vial labeling

    Practice changes:

    • Label the multi-dose vial with a patient addressograph label and a yellow “DO NOT USE AFTER _______” label.
    • Flag patient addressograph label on the side of vial and place a yellow “DO NOT USE AFTER _______” label on the vial. Do not cover drug name, lot number or expiry date on vial.
    • Most multi-dose vials can be used up to 28 days after opened or as per manufacturer’s guidelines, which may change depending on the brand. Check the manufacturer label on the vial for beyond-use date. If not specified or if unsure, contact pharmacy.
    • Some known current exceptions in FH are: dalteparin multi-dose vial (14 days) and octreotide multi-dose vial (15 days). Note: Insulin vials can be kept at room temperature for 28 days once removed from the fridge. Keep opened vial in the patient’s medication drawer.
    • Due to limited supply, each site to order only two boxes of labels from stores. Send a stores requisition using FHA # 314299. Each box contains 2 rolls of 500 labels each.


  • Vaccine documentation requirements

    Practice changes:

    If you administer a vaccine, document brand name, lot number, expiry date and body site on the Medication Administration Record (MAR), or alternatively, in clinical areas where the MAR is not used, where you usually document medication administration.

    •  Vaccines stocked in an Automatic Dispensing Cabinet (ADC)
    • A pop-up reminder will appear upon selection stating: “Document on MAR: brand name, lot number, expiry date and body site.”
    • Vaccines stocked at sites without an ADC – Wardstock item
    • Vaccine vial or storage container will have reminder label: “Document on MAR: brand name, lot number, expiry date and body site.”
    • Patient specific vaccines sent from pharmacy
    • A reminder comment will display on the patient specific label.
  • Transdermal medication patches
    • Never cut a transdermal patch to modify the dose. Consult a pharmacist for alternative therapies.
    • Never write directly on transdermal patch. Most manufacturers do not recommend writing on patches due to unknown risks, including risk of tear or puncture by pen/marker; interaction of ink and patch material; or effect of ink on medication delivery.
    • If needing to secure the patch, only use clear occlusive dressing (e.g. Tegaderm hydrocolloid) if indicated.

Students and faculty instructors who are completing student placements in Fraser Health are expected to apply any necessary changes in their practice to ensure that patients, clients, and residents continue to receive safe and quality care. Students and faculty instructors can only access this clinical protocol and resources pertaining to these clinical skills via FH Pulse when they are on a Fraser Health computer on a Fraser Health site.


Please contact the Student Practice Team.

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