From Mrs S. Glass, MRPharmS
SIR,—I recently received a Health and Safety Guide from the National Pharmaceutical Association which suggested that I carry out a risk assessment in the pharmacy.
I looked round the dispensary and found an accident waiting to happen on the generics shelves.
Now that we are carrying a full range of patient packs it has become obvious that safety has been sacrificed to conformity of pack and the company logo, not to mention the cost saving in having all of a company's products packed in the same box which is merely overprinted with the drug name and strength - all in the same typeface.
The possibility of mistakes in dispensing is increased since one no longer has sight of the product to jog one into the realisation of having picked up the diazepam 10mg pack instead of the 2mg. However, we are professionals and are trained to take note of the drug name and strength, so we must simply be more vigilant.
What concerns me is situation in the patient's home. Bendrofluazide, glibenclamide thyroxine, nitrazepam, diazepam, frusemide, gliclazide, naproxen, trimethoprim, allopurinol, digoxin - all in very similar boxes with, in some cases, the same strength profile in the hands of an elderly patient who cannot find his or her glasses, let alone the confusion caused by the similar looking foil being replaced in the wrong box so that even when the glasses are to hand, the wrong medicine is taken at the wrong time.
I feel that it is simply a matter of time before we read the coroner's court report of medicine confusion leading to death.
Generics manufacturers need to address the problem. Uniform packs may look good and be the cheapest alternative but they are very unsafe.
Sheila Glass
Ramsbury, Wiltshire