The Pharmaceutical Journal
Vol 270 No 7244 p514
12 April 2003

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Letters to the Editor

Labelling

Manufacturers should make reading labels easier

From Mr A. R. Cox, MRPharmS

Keith Stead (PJ, 29 March, p437) is correct in stating that the advice to professionals should always be "look at and read the label" — but he perhaps misses the point that Lord Hunt attempted to make.

Humans are fallible, occasionally making poor responses to information. The incorrect reading of medicine labels by health professionals cannot be avoided merely by telling people to concentrate more on the job in hand. Slips and lapses, which account for many medication errors, are neither fully amenable to training nor threats, since they occur at an unconscious level.

Several thought processes humans have developed in order to function efficiently in the world they live in conspire to make human errors inevitable.¹ People make sense of the world by matching inputs to their existing knowledge — "similarity matching". If a similar looking product is used, it may be matched to a previously used product. More frequently occurring inputs in a particular circumstance may be incorrectly chosen — "frequency gambling". For example, perceiving a similar looking lignocaine ampoule as the expected sodium chloride 0.9 per cent ampoule when administering an intravenous flush.

Decisions based on limited data, such as the initial glance at pharmaceutical packaging, may interfere with the later interpretation of improved information upon reading the label — "confirmation bias". Once the mind has incorrectly perceived the lignocaine as sodium chloride 0.9 per cent, it does not wish to discount this likelihood.

Poor packaging increases the risk of misinterpretation and reduces the chance of subsequently detecting errors.

Lord Hunt's comments that labelling "should let patients, carers and health professionals identify at a glance the information" should be taken in the correct context. Professionals and patients should not have to search for critical information for the safe use of a product.

Product packaging and labelling should serve only one purpose: the clear unambiguous identification of the drug. By all means, encourage professionals to read labels, but let us also encourage manufacturers to make it easier for them to do so safely.

Anthony Cox
Adverse Drug Reactions Pharmacist
West Midlands Centre for ADR Reporting

"CD POM" should appear on packaging

From Mrs A. R. Storey, MRPharmS

I have recently been informed by Napp Pharmaceuticals that it is not a mandatory requirement to have "CD POM" printed on the outer carton of a Schedule 3 Controlled Drug. Under the British National Formulary monographs for Schedule 3 CDs, each drug has "CD" printed next to the brand name. Schedule 3 CDs include buprenorphine and temazepam, both of which are subject to safe custody requirements.

In my experience in the hospital environment, the regulations governing the supply and storage of CDs cause constant confusion among nursing staff. Would it not, therefore, be sensible for drug companies to print "CD POM" on boxes to indicate that nurses should store these medicines in the CD cupboard and not in the ward medicines trolley (or worse).

I would assume that normally, the reason for putting "CD" on a box is to tell the person handling or dispensing the medicine that certain requirements need to be met. Surely something as simple as putting "CD POM" on the outer cartons of any medicines which are subject to safe handling requirements is a small thing for drug companies to do in order to avoid the confusion this sort of inconsistency (legal or otherwise) causes.

Amanda Storey
West Heath Hospital,
Birmingham

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