A few simple precautions can reduce the number of dispensing errors caused by different medicines or product strengths being packed in boxes that look similar, the procurement and distribution interest group of the Guild of Healthcare Pharmacists has been told. Mrs Andrea Patel told the group on November 9 that dispensing errors caused by ambiguities in packaging were commonplace but were accepted as something that just had to be lived with. However, steps could be taken by both hospital pharmacies and manufacturers to reduce the incidence of these errors. Mrs Patel, the winner of the guild's 1999 Pharmacia & Upjohn award, had set out to discover what the most common errors were, where they occurred and what could be done to prevent them. A survey of 33 hospitals had revealed that the most frequent sources of error were:
Other errors occurred for an assortment of reasons, such as active ingredients that had similar names, she said. Often, packs were distinguishable when looked at in isolation but in pharmacy stores or dispensaries, when hundreds of boxes were stacked up together, it became much more difficult to tell them apart. Mrs Patel discovered that patients received the wrong medicine most commonly as a result of errors made on wards because errors made within pharmacies were generally identified before medicines left the department. Both the Medicines Control Agency and the Royal Pharmaceutical Society resisted the idea of colour coding and other identifying features on the basis that they stopped people from reading packs. "It is a nice idea but it is not working. People often read what they want to read," Mrs Patel said. She suggested that pharmacies and manufacturers took the following steps:
There was no place for blame when it came to this type of error. It was a problem for everyone and everyone should tackle it together, she said. The results of the study would be made available on www.uclhsolutions.com on December 1, Mrs Patel said.