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 Build a Safer Medication
System
by Daphne Allen
In its recent report on medication
errors, the Institute of Medicine (IoM) cites unit-of-use packaging
as one way to curb them. Diane Cousins, R.Ph., vice president of the
U.S. Pharmacopeia's department of patient safety, standards
division, thinks it's a good idea.
For instance, "the most effective way to avoid errors in the use
of prescription drug samples is to prepare packaging for the
end-user, especially if it is the patient," says Cousins.
"Consideration [should be given] to the end-user at early stages of
design."
 Cousins advises
packagers to ask themselves these two questions: "What is the
intended dose? Does the packaging support it's proper use?"
It sounds pretty basic. But after
studying medical errors for nearly 15 years, Cousins has plenty of
examples of how patients are not considered. For instance,
"if the typical dose is two tablets, but packaged singly, patients
will get confused. Samples, though, are often packaged with two
tablets together, when the dose is one tablet."
"Patients are known for noncompliance," she continues. She points
to one patient described in the report who was chronically
noncompliant. Given samples of antibiotic and a doctor's orders to
take them all, she went home and took them all - at once.
 Fighting medication
errors isn't a new battle for USP. It has operated its medication
error-reporting program called MEDMARX since 1998. "There are a
number of packaging and labeling errors reported," says Cousins.
USP is considering a standard for Tall-Man Lettering, a technique
that involves capitalizing certain parts of drug names to call out
name differences from similarly looking or sounding drugs. USP also
looked at the design of injection labeling in the 1990s in an effort
to reduce clutter and issued several recommendations. "The effect of
an injection is immediate, so the result of an error with an
injectable drug is a rapid unintended response," she says. "Despite
these recommendations, we haven't seen a lot of improvement in the
labels of these products."
 On January 11, 2007,
FDA, USP, and the Institute of Safe Medication Practices will be
looking at this very topic as it examines small-volume and
large-volume parenteral drug labeling. Cousins also adds that
packagers should consider how pharmacists dispense products. "Maybe
we should package products so that pharmacists don't have to count
out a number of dosage units for prescriptions delivered to the
patient," she ponders.
She believes that the IoM report is being taken just as seriously
as its previous one, To Err Is Human-Building a Safer Healthcare
System. Let the work begin.
Daphne
Allen
Editor | 
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