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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1177.
PMCID: PMC2128642

Agency launches advice to reduce number of prescribing errors

The National Patient Safety Agency (NPSA) has called for the number of preventable errors in the dispensing of drugs to be reduced.

Launching two new additions to its “Design for Patient Safety” series, the agency aims to offer guidance for drug dispensers in England.

The booklets are intended to help professionals ensure that labelling and design are clear and accurate and that dispensing environments are safe and help to reduce the likelihood of errors.

The agency’s chief executive, Martin Fletcher, said, “The proportion of errors is very small, but the number needs to be reduced. Many dispensing issues can be resolved through simple redesign of space or procedures.

“All dispensing environments need to anticipate simple human error and where possible ensure the environment and procedures minimise the likelihood of it happening.”

The key recommendations made in the guidance include:

  • Designing dispensaries that encourage a safe and effective flow of work
  • Patients’ waiting areas that allow for confidential discussions about their drugs
  • Using bar codes on drug packs to aid accuracy checking
  • Ensuring that dispensing labels are clearly laid out, with text in a size that patients can read easily
  • Placing labels on packaging in a way that does not obscure important information or, where this is not possible, on smaller packets and tubes, using “flag” labels, and
  • Directly labelling containers rather than outer packaging.

The guidance says that “good design reduces errors in practice.” The layout of dispensing areas and the design and presentation of information on dispensing labels are, if done badly, the two areas that are most likely to result in errors, it says.

“Many of these recommendations will be simple and relatively inexpensive to implement,” Mr Fletcher said. “Others will need a certain degree of business and financial planning. Although not mandatory, the NPSA hopes that dispensaries will work towards these recommendations over time.”

Hemant Patel, president of the Royal Pharmaceutical Society, said that pharmacists were “only human” and that mistakes in the dispensing of drugs could be made.

“We need to take an overview of safe systems and how medicines are used in practice. This series of design guides provides practical examples of how professionals working in dispensaries can put this into practice.”

Mr Patel added that health care had been “relatively slow” in using design to improve care of patients and said that it needed to learn from other industries to do better in the future.

“We want to continue to aim to make Britain the safest place in the world to receive medicines,” he said.

Articles from The BMJ are provided here courtesy of BMJ Publishing Group