The Pharmaceutical Journal
Vol 268 No 7190 p397-401
23 March 2002

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Letters to the Editor

Packaging

Not the only cause of errors

From Mr S. J. Eastham, MRPharmS

I read with interest the news item "Pharmacists should use buying power to change unsafe packaging and labelling of medicines" (PJ, 23 February 2002, p233).

At Boots The Chemists, we have used our buying power to influence pack design and labelling on a number of occasions. Indeed, considering the impact of pack design on patient safety is one of the criteria we use in the purchasing of generic medicines.

On an ongoing basis, if we become aware that particular products are causing problems, we initiate a review of the supply of that product. For example, where two products are easily confused, we may change one product so that there is a marked difference in packaging of the two items.

However, a response should not be limited to changing suppliers or pack design. Although recognising that pack design and labelling can contribute to errors, other causes should not be overlooked. At Boots we are addressing this through a dispensing incident management process that helps pharmacists analyse errors to understand the contributory factors, whether from task, workplace, team or individual sources. I strongly advocate an approach that takes into account the whole range of factors that may be at work, and proactively devising strategies to manage each one.

S. Eastham
Head of Clinical Governance
Boots The Chemists
Nottingham

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