From Mr R. J. S. Shaw, MRPharmS
SIR,—I wholeheartedly agree with the sentiments expressed by Whitaker and Hughes (PJ, November 25, p790) concerning poor packaging and labelling design leading to errors.
I spend a considerable amount of time responding to reports of mistakes and "near misses " in dispensaries, in wards and, perhaps most commonly, in operating theatres, nearly all of which are associated with product presentation and labelling in particular.
In my opinion, most of the errors would be avoidable if only the pharmaceutical industry would take a more responsible attitude to the needs of users.
I do, of course, acknowledge that products should not have to be in different shaped bottles or boxes to be easily distinguishable; but I also know that the important information (drug common name and strength per unit dose) are not always clearly stated. This is a particular problem with, for example, ampoules which are separated from their outer packaging before use. Yes, we know these are often small containers and there are space constraints, but it is still possible to label clearly.
In my view, labels are getting worse and I am becoming more angry with some manufacturers' obduracy and, dare I say, arrogance in responding to our complaints. Often they cite EC regulations or hide behind "Medicines Control Agency approval " for not responding. This will not do. Bad labelling and packaging is costing lives.
There are also steps which pharmacists can take, and I am mainly concerned with secondary care. We may have to highlight strengths ourselves, or even locate high risk medicines such as strong potassium chloride solution in a separate place with controlled access. What we need, however, is a formal risk management approach and we need the manufacturers to work with us to recognise users' needs.
R. J. S. Shaw Academic Pharmacy Practice Unit, University of East Anglia, Norwich