We continue to have PCA pump programming errors due to lack of interoperability. We currently have only two concentrations of PCA and plainly label them in the library with concentration and "high" designation behind the high concentrations. The syringes themselves have several "high concentration" labels on them and only the standard concentrations are stored in ADCs. We also require an independent double check, but people still miss the concentration difference and pick the wrong syringe which causes a 10 fold overdose in some instances. Can anyone share mitigation strategies they have taken to prevent this problem?