Package Design Affects Accuracy Recognition for Medications

Abstract

Objective:Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors.Background:An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors.Method:In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated.Results:The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications.Conclusion:Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications.Application:A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose.

Using clinical simulation to study how to improve quality and safety in healthcare

“…The error rate remained low with no significant change, but nurses were significantly quicker in their preparation with the new labelling system. These results contrast with a previous on-screen experiment, where the error rate deceased with the new system 99…”

“…Researchers timed the preparation of each medication chart using a stopwatch and counted the number of errors in preparation with the standard labelling system. They repeated the experience 3 months later, using a new labelling system proposed in the literature by Endestad et al 99…”

How to prevent medication errors: a multidimensional scaling study to investigate the distinguishability between self-injection platform device variants

“…In so doing, the study differed from prior research that typically asked participants to explicitly prioritize from a pre-defined list of design features defined ex ante [e.g. 47,50,56]. The results presented here underscore the unique value of the inductive research design.…”

“…Participants were neither asked to generate relevant attributes nor to prioritize between them from a pre-defined list [e.g. 47,50,56]. The risk of introducing either participants' or researchers' biases is thus lower with MDS compared to other methodologies that may require direct evaluation of device attributes.…”

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting

“…To counter the risk of unconsciously taking, administering or dispensing more than one product with the same active ingredient, Endestad et al 19 recently explored the effect of a redesigned standardised labelling of medication packages. The new design includes prominent placement of INN(s) and strength(s), written in black on a white background, and placed in the upper right corner of the front of the package ( figure 1) .…”