Medication error packaging

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

The FDA receives and reviews about 300 medication error reports each month and classifies them to determine the cause and type of error. Depending on the findings, the FDA can change the way it labels, names, or packages a drug product. In addition, once a problem is discovered, the FDA educates the public on an ongoing basis to prevent repeat errors. 

Berman A. Reducing medication errors through naming, labeling, and packaging. / Med Syst. 2004 28 9-29. 

Automation can reduce medication errors if it is implemented properly because it reduces the number of manual functions necessary to complete a task, thus reducing the chance for mistakes. Automation has helped to reduce the time that pharmacists spend preparing, labeling, and packaging medications, and this time can be reallocated to pharmaceutical care activities (Lewis, Albrant, and Hagel, 2002). 

Figure 30-6. Similar packaging might lead to medication errors.

Figure 30-7. Another example of packaging that might lead to medication error.

Numerous reports of medication errors are being reported, some of which have resulted in patient injury or death. In a number of these reports, a medication was mistakenly administered either because the drug container (bag, ampule, prehlled syringe and bottle) was similar in appearance to the intended medication s container or because the packages had similar labeling. Obviously, the severity of such errors depends largely on the medication administered. 

For nearly 33 years, the USP has been reporting programs for health care professionals to share experiences and observations about the quality and safe use of medications. This year, the USP Center for the Advancement of Patient Safety publishes its sixth annual report to the nation on medication errors reported to MED MARX (Table 6). It was observed that drug product packaging/labeling is one of the main courses of medication errors in hospitals. 

Other medication errors involving medicationdispensing devices reported to the USP have included the interchange of devices supplied with specific products. Each device packaged with a medication is calibrated for that medication based on the viscosity and concentration of the specific liquid it delivers. These devices are not calibrated in any standardized way some are measured in milligrams (mg), others in... 

A wholly owned subsidiary called Medical Error Recognition and Revision Strategies (Med-E.R.R.S. ) which works confidentially with pharmaceutical companies to predict error potential and thereby avoid problems that might stem from proposed drug names, labels, and packaging. 

Healthcare professionals can either complete a report form or contact the ISMP—Spain directly by e-mail, fax, or telephone to report medication errors with complete confidentiality. The types of medication errors submitted include confusion over look-alike or sound-alike drug names, ambiguity or similarity in packaging or labeling. 

Compounded drug formulations for special populations. Packaging, labeling, nomenclature, and dosage form characteristics for medicines to reduce medication errors. 

This would be a medication error and would be administering 200 mg of medication, or four times the dose prescribed. MEDICATION MEMORY JOGGER Most pharmaceutical companies package the medication in amounts that are usually prescribed by the HCP. If the nurse uses more than one vial to administer a medication, then the nurse should seek clarification of the prescription. 

A study of the United States Pharmacopoeia voluntary Medication Errors Reporting Program data over a one-year period revealed that in approximately 30% of the fatalities labeling or packaging was clearly cited as a contributory factor to medication errors that resulted in fatalities [11]. The types of labeling or packaging-related problems encountered are shown in Figure 6.1 [11]. 

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