Search the hub
Showing results for tags 'Labelling / packaging/ signage'.
-
Content Article
WHO: Medication with harm – Policy brief (7 March 2024)
Patient Safety Learning posted an article in Medication
Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm.- Posted
- 1 comment
-
- Medication
- Human error
- (and 4 more)
-
Content ArticleThe US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included. See also our Medication error traps gallery
- Posted
-
- Human error
- Labelling / packaging/ signage
-
(and 3 more)
Tagged with:
-
Content ArticleA service providing bilingual medication information is helping to reduce healthcare inequalities and medical errors. Pharmacies across London are benefitting from the support of Written Medicine; a service providing bilingual dispensing labels in patients’ language of choice.
- Posted
-
- Pharmacist
- Pharmacy / chemist
- (and 5 more)
-
Content ArticleMedication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety.
- Posted
-
- Medication
- Labelling / packaging/ signage
- (and 4 more)
-
News ArticleValproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change. Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy. The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines. Minister for Public Health, Maria Caulfield, said: “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully. “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.” Read full story Source: MHRA, 11 October 2023
- Posted
-
- Medication
- Labelling / packaging/ signage
- (and 7 more)
-
Content ArticleThis is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023.
-
EventMedication errors are a leading cause of patient harm globally. Look-alike, sound-alike (LASA) medicines are a well-recognised cause of medication errors that are due to orthographic (look-alike) and phonetic (sound-alike) similarities between medicines, which can be confusing. Look-alike medicines appear visually the same with respect to packaging, shape, colour and/or size, while sound-alike medicines are similar in the phonetics of their names, doses and/or strengths. Confusions can occur between brand-brand, brand-generic or generic-generic names. Organisations need to prospectively design and implement strategies to identify LASA medication errors and build a robust system that intercepts them before they result in patient harm. At this webinar, WHO will launch their publication “Medication Safety for Look-alike, Sound-alike Medicines”, as part of the WHO technical series on “Medication Safety Solutions”. Preventive strategies that can be implemented by healthcare professionals and organizations will be discussed on how to prevent LASA errors to reduce the risk of medication-related harm. Register
-
Content ArticleMedication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation. Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub
- Posted
-
- Medication
- Human factors
- (and 4 more)
-
Content ArticleThis paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator’s high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from “designer error” rather than “user error”. Guidelines that define a container’s shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.
- Posted
-
- Medication
- Human factors
- (and 4 more)
-
Content ArticleThis study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
- Posted
-
- Anaesthesia
- UK
- (and 5 more)
-
Gallery Image
Fentanyl and naloxone.jpg
Patient Safety Learning posted a gallery image in Medication
-
Gallery Image
Noradrenaline and tranexamic acid.jpg
Patient Safety Learning posted a gallery image in Medication
Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).© Healthcare UK
- Posted
-
- Medication
- Labelling / packaging/ signage
-
(and 1 more)
Tagged with:
-
Gallery Image
Bupivacaine alongside sodium choloride.jpg
Patient Safety Learning posted a gallery image in Medication
- Posted
-
- Medication - related
- Labelling / packaging/ signage
- (and 1 more)
-
News Article
Drug shortages linked with medication errors, study results suggest
Patient Safety Learning posted a news article in News
A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.” Read full story (paywalled) Source: The Pharmaceutical Journal, 11 October 2022- Posted
-
- Medication
- Human error
- (and 4 more)
-
Content ArticleConfusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
- Posted
-
- Medication
- Communication
- (and 5 more)
-
Gallery Image
Bupivacaine and sodium chloride
Patient Safety Learning posted a gallery image in Medication
- Posted
-
- Medication
- Human factors
-
(and 1 more)
Tagged with:
-
Gallery Image
Sodium chloride and levobupivacaine
Patient Safety Learning posted a gallery image in Medication
-
Gallery Image
Clobazam.jpg
Patient Safety Learning posted a gallery image in Medication
-
Gallery Image
Sodium Cholride and Metronidazole.jpg
Patient Safety Learning posted a gallery image in Medication
-
Gallery Image
Sodium Chloride and paracetamol solution.jpg
Patient Safety Learning posted a gallery image in Medication
- Posted
-
- Medication
- Labelling / packaging/ signage
-
(and 1 more)
Tagged with:
-
Gallery Image
Aspirin.jpg
Patient Safety Learning posted a gallery image in Medication
- Posted
-
- Medication
- Patient
-
(and 1 more)
Tagged with:
-
Content ArticleThe US Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations contains abbreviations, symbols, and dose designations which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.
- Posted
-
- Medication
- Medication - related
- (and 8 more)