The Pharmaceutical Journal
Vol 271 No 7259 p117
26 July 2003

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Letters to the Editor

Packaging

Don't place packs upside down

From Mr Z. Silver, MRPharmS

In your meeting report (PJ, 12 July, p62), patient safety was considered, accompanied by a photograph of packs of amiodarone and amitriptyline tablets. The amitriptyline packs featured are marketed by Alpharma Ltd. I am familiar with its packaging, and consider it to be well designed and thought through.

The 10mg strength of amitriptyline shows "10mg" on a white background; the 25mg strength on a pink background and the 50mg strength on a red background. This is, to my mind, a sensible scale — the lighter the colour, the weaker the tablet; the darker the colour, the stronger it is.

If you look at the picture accompanying the article you can see the pack of amitriptyline 10mg (in the stack behind the opened pack with a cross) is upside down on the shelf. Similarly, the top pack of the 50mg strength (on the right) has also been placed on the shelf upside-down.

Surely the single, initial, most important check when dispensing is to read the label on the pack and ensure that you have selected the right box. If the packs are placed on the shelf upside down it makes reading the label that much harder.

I was told many years ago not to place packs on the shelf upside down — it gives them a headache. How much of a headache does a pharmacist get if he supplies the wrong item?

Zvi Silver
Edgware, Middlesex

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