From Mr S. Whitaker, MRPharmS, and Mr R. I. Hughes, MRPharmS
SIR,—In their conclusion to "Errors in prescribing, dispensing and administration of carbamazepine" (PJ, November 18, p756), Mack et al state that 14 cases of inadvertent intoxication with carbamazepine might have been prevented by changing the appearance of the products' packaging.
We read in the same issue, in your report of her presentation to the Guild of Healthcare Pharmacists (p744), that Andrea Patel, holder of the guild's 1999 Pharmacia & Upjohn award, considers that "errors caused by ambiguities in packaging were commonplace". She also states, controversially in our view, that they "were accepted as something that just had to be lived with". We also learn, from her report of a survey of 33 hospitals,that the two most frequent sources of error involve either "different strengths of product in almost indistinguishable boxes" or "different medicines with similar names made by the same manufacturer".
In these two reliable reports, from disparate yet authoritative health care sources, we are provided, simultaneously, with two separate, measured views of the extreme hazards that are presented by today's heinously negligent standards of packaging and labelling in our own pharmaceutical industry. All of us know that these hazards are extreme, from the risk of patient death with its dreadful consequences for all involved, to the painful and miserable agonies as so graphically catalogued in the Sheffield paper.
Andrea Patel states: "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." Blame or not, the underlying cause of far too many errors of this type can reliably be attributed to the disturbingly high incidence of amorphous packaging and the indistinctness of labelling. This is a very serious and longstanding problem that each and every one of us should tackle together. We have attempted to start this process by defining and illustrating the problem's depth and scale at the website www.
patientpacks.com. There we have also attempted to explain how salient features of packaging and labelling contribute directly within the process of error.
Although patientpacks.com has a satirical tone, intending to address this deadly serious problem with good humour, its coldly pertinent information and illustration should leave no visitor in any doubt of our own sentiments. We continue to be outraged by the pharmaceutical industry's arrogance in continuing to ignore front-line pharmacy's call for the recognition, review and all-round improvement of this deadly situation.
The prime strategic objective of the Association of the British Pharmaceutical Industry is stated as being "to safeguard the interests of patients, and enhance the health of the nation, through effective use of medicines". We openly invite and challenge the president of the ABPI to uphold his association's objects by joining with us in starting to tackle this problem. We respectfully suggest that, having viewed the content of
patientpacks.com, he should add his name to the site's appeal in support of universal review — and actively seek his peers' assent on making a start. We would further hope that he would find support and every encouragement in the corridors of Lambeth and St Albans. He will, most certainly, find both in dispensaries, wards, operating theatres, nursing homes and sickrooms throughout the land.
Simon Whitaker Cardiff Idris Hughes Trefriw, Gwynedd