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Packaging

Potential for errors

From Ms M. G. B. Ryan, MRPharmS

I am deeply concerned about the number of generic drug packs of similar size, shape and colour that are currently available within primary care. The potential for mix up between different drugs is heightened by the similarity of the drug containers. There is a higher potential for errors to happen within a pharmacy when dispensing but also by patients at home on a number of medicines. This also has to be viewed in the context that over half of prescriptions are prescribed for those aged over 60 years, whose eyesight is more likely to have deteriorated.

Community pharmacists, locums and a number of general practitioners have commented on the similarity in packs. One concerned GP recently wrote to me as he found a patient taking bendrofluazide instead of diazepam because the pack and foil contents were almost identical. This is also compounded by the writing on the foil packs, which is difficult to read owing to its small print size on a reflective surface.

Here is an area where the Royal Pharmaceutical Society should be able to influence the generic pharmaceutical companies to change this situation and resolve this risk management issue.

Margaret Ryan
Prescribing Adviser
Lomond & Argyll Primary Care NHS Trust

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