The Pharmaceutical Journal
Vol 275 No 7375 p606
12 November 2005

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· Adverse reactions
· Drug interactions (2)
· Packaging
· GHP (2)
· Pricing
· Clinical governance
· The profession
· Pharmacy workforce
· Communication
· Registration

Letters to the Editor

Packaging

Tablet markings should be considered in safe design

From Dr N. J. Langford, MRPharmS, and Ms E. M. Graham-Clarke, MRPharmS

The recent article on design (PJ, 22 October, p507) highlights important safety issues with respect to tablet packaging. Unsurprisingly, in view of EU legislation, considerable cost and effort is being placed into making product packages look distinctive to help avoid error. However, the process should not stop here. Little regulation presently exists over tablet markings. The PJ ¹ and others² have shown that identical tablets can contain different ingredients. This has proven to be confusing not only to patients but also to health care professionals. Legislation is urgently required to produce a uniform marking code for solid dosage forms. Indeed it has been calculated that using just four different characters provides over 1,000,000 potential combinations.³ Easy tablet identification that can be uniformly recognised can only help to improve patient safety. The pharmaceutical industry as well as the regulatory bodies need to adopt the “whole package (tablet included)” to improve patient safety.

Nigel Langford
Emma Graham-Clarke
City Hospital,
Birmingham

References

1. Toothill C. Two almost identical tablets (letter). Pharmaceutical Journal 2004;273:149.

2. Graham-Clarke E and Langford NJ. Confusing tablets. Lancet 2005;366:154.

3. Ferner RE. Reducing medication errors. JAMA 2001;286:2091.

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