From Mr P. D. Burgess, MRPharmS
SIR,—I note that the Royal Pharmaceutical Society’s professional
standards directorate recognises there is a problem with packaging standards
as it is now highlighted in the Law and Ethics Bulletin titled “Handling
products in packaging of similar appearance” (PJ, October 14, p552).
However, I think to advise pharmacists to be particularly vigilant is just not
enough.
Did anyone else watch the series of television programmes on how medical errors
can arise? The message was that the system should be changed rather than blame
the individual doctor, pharmacist, etc. Here is our poor system just inviting
some serious error to arise. I have already heard of one incident where a patient
was suffering fits because phenytoin had been confused with quinine. Surely
we do not have to wait until there is a fatality before there is some action.
The only action I have been impressed by is on a website (www.patientpacks.com),
but someone needs to be able to enforce satisfactory standards. I think the
Society should be involved and exercising some control over pharmaceutical companies’
standards of packaging as it does over the rest of the dispensing process.
I do not wish to detract from the seriousness of the issue of bad packaging
design but perhaps sometimes it is just as well patients do not read packs too
well. Every time I add water to dispense Distaclor syrup, I wonder if the product
is going to be returned because under the section labelled “Note to the
patient” it reads, “If red ring broken do not use”.
I trust no one thinks that to issue a bulletin can be relied on to prevent a
serious error. I regularly see errors in deliveries from wholesalers and I know
there have been more than enough errors by pharmacists already. Are we expected
to say as we hand the script out to the elderly patient, “Now please be
particularly vigilant. Remember to check and recheck the pack to ensure that
you do not take the wrong medicine”?
Please can somebody take on the responsibility and change the system that allows
confusing packaging to be issued.
Paul Burgess
Kingston, Surrey