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Packaging
Can packaging reduce errors?
From Mr E. Muammar, MRPharmS
I refer to Alan Nathan’s report
on “Fair blame” agreements (PJ, 5 June, p707) which suggests that health professionals would carry
all the blame for dispensing errors.
Reading this I recalled an incident where a patient queried the tablets
delivered to her because they were white as previously dispensed but this
time had the inscription “Slow-K”. I checked her records and
it turned out she was prescribed Slow-Sodium. This was an accident waiting
to happen — two different sugar-coated tablets with similar names
kept next to each other in plastic containers. I delivered the correct
tablets to her.
Although I agree that the pharmacist had made an error, I believe that
a great part of the blame should fall on the manufacturer and the licensing
authority which approved the marketing of two products that can be easily
confused.
I was thinking about how to prevent such errors when I noticed two packs
of over-the-counter paracetamol (made by Mandanol) which had illustrations
of the tablets on the outer packaging. These illustrations assist in identifying
the contents. If true pictures of both sides of the tablets were printed
in an oblique angle on the patient information leaflet and on both patient
pack and bulk containers, it would be a great help to those who check monitored
dosage systems (some compartments have several white round blank tablets
with no identity stacked on top of each other).
Another benefit of printing codes on tablets is to assist in quickly pinpointing
a possible cause of poisoning, overdosage, or attempted suicide. It will
also help identify particular manufacturers when patients insist on a certain
brand.
In addition, packaging can help to prevent dispensing expired medicines.
If the manufacturers devised a colour coding or a bar coding scheme to
indicate the month and year of expiry, these colour codes could be read
easily from a few yards away. This would allow quick rotation of the stock
and reduce the likelihood of dispensing and wasting outdated medicines.
Elias Muammar
Chandlers Ford,
Hampshire |
The
Pharmaceutical Journal