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Background: Labelling is a strategy that contributes to the correct and faster identification of drugs, minimizing misidentification. There is a gap in knowledge on optimal labelling standards for intravenous (IV) devices applied to the care of critically ill patients. Aim: The goal of this article was to map existing knowledge on the labelling of IV drug delivery devices in critically ill patients for the prevention of medication errors. Study Design: This was a scoping review conducted according to the JBI methodology in the LILACS, MEDLINE, CINAHL, IBECS, Scopus, Embase and Web of Science databases, and on the websites of specialized institutions. Searches were conducted up to December 2022 for scientific articles and grey literature that addressed the labelling of IV devices in intensive care units, emergency departments, and anaesthesia units. The data were collected using a structured form and were later classified, summarized, and aggregated to map the knowledge related to the review question. Results: Twenty‐one documents were included, which demonstrated variability in label use with IV drug delivery devices. The following features of structure and design stood out: printed format, colour coding, letter size differentiation, and the use of sturdy material. In terms of information, the name of the drug, dose, date and time of preparation, identification of the patient, and who prepared it were found. Conclusions: The identified patterns contributed to the reduction of drug misidentification and the development of timelier drug labelling and administration. Relevance to Clinical Practice: The evidence supports the development of standardized labels for the prevention of medication errors. [ABSTRACT FROM AUTHOR]

Knowledge of and expertise in insulin prescribing is crucial for health care providers who care for people with diabetes. This article reviews the available insulin preparations, how they are packaged, and nuances related to storage and use that inform the prescribing of this life-saving medication for patients. Insulin prescribing that is done correctly will save time and reduce problematic errors that could put patients at risk. [ABSTRACT FROM AUTHOR]

This 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. [ABSTRACT FROM AUTHOR]

Purpose: Patient safety errors can arise due to similarity in packaging of medications. We aimed to describe the clinical features of patients presenting with accidental application of joint pain liniments and gum lotion in the eye due to confusion arising from similarity in packaging.Methods: This was a retrospective case series with eight consecutive patients presenting from December 2020 to August 2021 with history of accidental application of joint pain liniments or gum lotion in the eye instead of eye drops. All patients underwent visual acuity assessment and slit-lamp examination with fluorescein staining of the cornea to look for corneal involvement and was reassessed till complete resolution.Results: Of the eight patients, three were males and five were females. Seven had accidentally applied joint pain liniment, while one had applied gum lotion into the eye. Five of them had corneal involvement ranging from punctate erosions to near-total epithelial defects. Two patients needed referral to a tertiary center and hospital admission. Treatment duration ranged from 2 days to 1 month. Two patients were lost to follow-up.Conclusion: This study highlights patient safety errors arising from confusion of medication due to similar labeling and packaging of different drugs. While there was no permanent morbidity, such confusions lead to needless discomfort and waste of time, money, and effort for the patient as well as the health-care system. [ABSTRACT FROM AUTHOR]

Objective: To reduce drug dispensing errors through development of the barcode scanning check system in drug dispensing. Methods: Drug barcode types for various drugs were fed in the drug dictionary of the hospital information system, and commodity codes on drug packaging and/or electronic drug regulatory codes were also installed in the system, and a validation barcode switch was placed in dispensing windows to add another validation barcode process during drug dispensing. Results: After 6 months of application, the system successfully intercepted 141 drug dispensing errors due to similar packaging or similar brand names. Inventory check revealed that there was no inconsistency between accounts and drugs dispensed due to similar packaging or similar brand names. As a result, the load on pharmacists for checking was obviously relieved, work efficiency improved, and the average waiting time of the patients for taking drugs was shortened by 9.52%. Condlision: Barcode scanning check system for drug dispensing could help pharmacists to improve the accuracy and efficiency of drug checking, relieve work load at the drug dispensing window and shorten the waiting time of patients, with less input. For this reason, it is worth further promotion. [ABSTRACT FROM AUTHOR]

In Japan, the mean time spent on preparing and administering medications each day for everyone in care facilities has been reported to be 163 min. Most caregivers that administer medications to the elderly in care facilities have reported that this responsibility is a burden. We developed a drug distribution support device (DDSD) for caregivers, which was then installed in a group home and a 3-month monitoring experiment was conducted. Caregivers then answered a questionnaire survey on medication management burden pre- and post-DDSD use. The caregivers reported no difficulties associated with medication distribution using DDSD. The DDSD reduced the daily dispensing duration by an average of 3.5 min. The questionnaire survey showed no differences in items related to the reduction of errors, and the Family Caregiver Medication Administration Hassles Scale showed no reduction of burden on caregivers. However, whether the DDSD reduces medication management burden remains undetermined. [ABSTRACT FROM AUTHOR]

This section offers news briefs on medication errors as of November 2023. The Fellows of the American Society of Health-System Pharmacists has called upon the U.S. Food and Drug Administration to require bar codes on immediate container labels and to incorporate the medication's lot number and expiration date. Confusion between the actual medication cartons and demonstration cartons of Ryanodex (dantrolene sodium) has been reported by a hospital.

The article presents different cases of medication errors. An anesthesiologist inadvertently administered lidocaine at a rate of 30mg/minute instead of 30 mcg/kg/minute and the patient received 1,500 mg over 50 minutes rather than the intended dose of 85 mg. A pharmacy technician identified a look-alike labeling concern upon receiving a shipment of Enfamil Poly-Vi-Sol multivitamin drops and Polyvisol multivitamin & iron drops manufactured by Mead Johnson & Company.

The article offers information associated with the preparation and administration of medicines with a high potential for harm in a time-critical fashion. Topics discussed include electronic clinical decision tools to decrease chance of medication errors, essentiality of robust medicines management for the safe and effective use of drugs, accessing drugs for clinical efficiency and emergency treatment to mitigate drug misdirection and abuse.

Background: Patient safety is a significant challenge facing healthcare systems. The administration of medication is pivotal to patient safety, and errors in drug administration are associated with mortality and morbidity. In this study, we assessed the factors contributing to the occurrence and reporting of medication errors from the nurse's perspective. Methods: In this descriptive cross‐sectional study, we distributed a validated questionnaire to 367 nurses at a large public hospital and obtained a response rate of 73.4%. The questionnaire comprised 65 questions, including 29 on the causes of medication errors, 16 on the reasons why medication errors are not reported and 20 that estimated the percentages of the different medication errors actually reported. Informed consent was obtained from all participants, and the anonymity and confidentiality of participants’ information were preserved throughout the process. This study received institutional review board approval. Descriptive statistics were used for data analysis. Results: The main factors associated with medication errors by nurses were related to medication packaging, nurse–physician communication, pharmacy processes, nurse staffing and transcribing issues. The main barriers to the reporting of errors by nurses were related to the administrative response, fear of reporting and disagreements regarding the definitions of errors. Conclusion: Medication errors by nurses are related to medication packaging, poor communication, unclear medication orders, workload and staff rotation. To prevent medication errors, teamwork must be improved. All healthcare settings should emphasise awareness of the culture of safety, provide support and guidance to nurses and improve communication skills. We also recommend the use of integrated health informatics, including computerised drug administration systems. The limitations of this study include the potential for nonresponse bias associated with the sampling method. Further research is required to explore the complex and multidimensional causes of medication errors and review the responses of nurses regarding the errors reported. [ABSTRACT FROM AUTHOR]

Background No published study has been specifically designed to compare medication administration errors between original medication packaging and multi-compartment compliance aids in care homes, using direct observation. Objectives Compare the effect of original medication packaging and multi-compartment compliance aids on medication administration accuracy. Design Prospective observational. Setting Ten Greater London care homes. Participants Nurses and carers administering medications. Methods Between October 2014 and June 2015, a pharmacist researcher directly observed solid, orally administered medications in tablet or capsule form at ten purposively sampled care homes (five only used original medication packaging and five used both multi-compartment compliance aids and original medication packaging). The medication administration error rate was calculated as the number of observed doses administered (or omitted) in error according to medication administration records, compared to the opportunities for error (total number of observed doses plus omitted doses). Results Over 108.4 h, 41 different staff (35 nurses, 6 carers) were observed to administer medications to 823 residents during 90 medication administration rounds. A total of 2452 medication doses were observed (1385 from original medication packaging, 1067 from multi-compartment compliance aids). One hundred and seventy eight medication administration errors were identified from 2493 opportunities for error (7.1% overall medication administration error rate). A greater medication administration error rate was seen for original medication packaging than multi-compartment compliance aids (9.3% and 3.1% respectively, risk ratio (RR) = 3.9, 95% confidence interval (CI) 2.4 to 6.1, p < 0.001). Similar differences existed when comparing medication administration error rates between original medication packaging (from original medication packaging-only care homes) and multi-compartment compliance aids (RR = 2.3, 95%CI 1.1 to 4.9, p = 0.03), and between original medication packaging and multi-compartment compliance aids within care homes that used a combination of both medication administration systems (RR = 4.3, 95%CI 2.7 to 6.8, p < 0.001). A significant difference in error rate was not observed between use of a single or combination medication administration system (p = 0.44). Conclusion The significant difference in, and high overall, medication administration error rate between original medication packaging and multi-compartment compliance aids supports the use of the latter in care homes, as well as local investigation of tablet and capsule impact on medication administration errors and staff training to prevent errors occurring. As a significant difference in error rate was not observed between use of a single or combination medication administration system, common practice of using both multi-compartment compliance aids (for most medications) and original packaging (for medications with stability issues) is supported. [ABSTRACT FROM AUTHOR]

The article presents insights on a panel discussion about intravenous push administration practices. Topics covered include the risks associated with intravenous push medications, the clinicians' adherence to guideline recommendations for the administration of intravenous medications and the characteristics of an ideal ready-to-administer (RTA) system. Also mentioned is the assessment of medication delivery systems.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (, by calling 800-FAIL-SAFE, or via e-mail at . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language. METHODS: Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose). RESULTS: A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4). CONCLUSIONS: Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors. [ABSTRACT FROM AUTHOR]

Objectives To identify the practical problems that older people experience with the daily use of their medicines and their management strategies to address these problems and to determine the potential clinical relevance thereof. Design Qualitative study with semistructured face-to-face interviews. Setting A community pharmacy and a geriatric outpatient ward. Participants Community-dwelling people aged 70 and older (N = 59). Measurements Participants were interviewed at home. Two researchers coded the reported problems and management strategies independently according to a coding scheme. An expert panel classified the potential clinical relevance of every identified practical problem and associated management strategy using a 3-point scale. Results Two hundred eleven practical problems and 184 management strategies were identified. Ninety-five percent of the participants experienced one or more practical problems with the use of their medicines: problems reading and understanding the instructions for use, handling the outer packaging, handling the immediate packaging, completing preparation before use, and taking the medicine. For 10 participants, at least one of their problems, in combination with the applied management strategy, had potential clinical consequences and 11 cases (5% of the problems) had the potential to cause moderate or severe clinical deterioration. Conclusion Older people experience a number of practical problems using their medicines, and their strategies to manage these problems are sometimes suboptimal. These problems can lead to incorrect medication use with clinically relevant consequences. The findings pose a challenge for healthcare professionals, drug developers, and regulators to diminish these problems. [ABSTRACT FROM AUTHOR]

BACKGROUND: In October 2007, manufacturers voluntarily withdrew over-the-counter (OTC) infant cough and cold medications (CCMs) from the US market. A year later, manufacturers announced OTC CCM labeling would be revised to warn against OTC CCM use by children aged <4 years. We determined whether emergency department (ED) visits for CCM adverse drug events (ADEs) declined after these interventions. METHODS: We used National Electronic Injury Surveillance System- Cooperative Adverse Drug Event Surveillance data from 2004 to 2011 to estimate the number of ED visits for CCM ADEs before and after each intervention. RESULTS: Among children aged <2 years, ED visits for CCM ADEs decreased from 4.1% of all ADE ED visits before the market withdrawal to 2.4% of all ADE visits afterward (difference in proportion: -1.7%, 95% confidence interval [CI]: -2.7% to -0.6%). Among children aged 2 to 3 years, ED visits for CCM ADEs decreased from 9.5% of all ADE ED visits before the labeling revision announcement to 6.5% of all ADE visits afterward (difference in proportion: -3.0%, 95% CI: -5.4% to -0.6%). Unsupervised ingestions accounted for 64.3% (95% CI: 51.1% to 77.5%) of CCM ADE ED visits involving children aged <2 years after the withdrawal and 88.8% (95% CI: 83.8% to 93.8%) of visits involving children aged 2 to 3 years after the labeling revision announcement. CONCLUSIONS: After a voluntary market withdrawal and labeling revision, ED visits for CCM ADEs declined among children aged <2 years and 2 to 3 years relative to ADE ED visits for all drugs. Interventions addressing unsupervised ingestions are needed to reduce CCM ADEs. [ABSTRACT FROM AUTHOR]

The article presents information about medication safety issues, medication errors and strategies to prevent medication errors drawn from Australian incidents and US experiences. A discussion of medication errors and potential medication errors regarding human error and drug labeling errors is presented. Safety briefs on prescription drugs and safe practice recommendations are offered.

Objective. To study early experiences with multidose drug dispensing (MDD) among different groups of health personnel. Design. Qualitative study based on focus-group interviews. Setting. Primary health care, Trondheim, Norway. Main outcome. The importance of trust in the technology and in collaborating partners is actualized in the early implementation of MDD. Results. GPs, home-care nurses, pharmacists, and medical secretaries trusted the new MDD technology. The quality of the GPs'' medication records improved. However, health personnel, including the GPs themselves, would not always trust the medication records of the GPs. Checking the multidose bags arriving from the pharmacy was considered unnecessary in the written routines dealing with MDD. However, home-care nurses experienced errors and continued to manually check the bags. Nurses in the home-care service felt a loss of knowledge with regard to the patients'' medications and in turn experienced reduced ability to give medical information to patients and to observe the effects of the drugs. The home-care services'' routines for drug handling were not always trusted by the other groups of health personnel involved. Conclusion. Health personnel faced some challenges during the implementation of the MDD system, but most of them remained confident in the new system. Building trust has to be a process that runs in parallel with the introduction of new technology and the establishment of new routines for improving the quality in handling of medicines and to facilitate better cooperation and communication. [ABSTRACT FROM AUTHOR]

OBJECTIVE: A voluntary market withdrawal of orally administered, over-the-counter, infant cough and cold medications (CCMs) was announced in October 2007. The goal of this study was to assess CCM-related adverse events (AE5) among children after the withdrawal. METHODS: Emergency department (ED) visits for CCM-related AEs among children <12 years of age were identified from a nationally representative, stratified, probability sample of 63 US EDs, for the 14 months before and after announcement of withdrawal. RESULTS: After withdrawal, the number and proportion of estimated ED visits for CCM-related AEs involving children <2 years of age were less than one-half of those in the prewithdrawal period (1248 visits [13.3%] vs 2790 visits [28.7%]; difference: -15.4% [95% confidence interval [Cl]: -25.9% to -5.0%]), whereas the overall number of estimated ED visits for CCM-related AEs for children <12 years of age remained unchanged (9408 visits [95% Cl: 6874-11 941 visits] vs 9727 visits [95% Cl: 6649 -12 805 visits]). During both periods, two-thirds of estimated ED visits involved unsupervised ingestions (ie, children finding and ingesting medications). CONCLUSIONS: ED visits for CCM-related AEs among children <2 years of age were substantially reduced after withdrawal of over-the-counter infant CCMs. Further reductions likely will require packaging improvements to reduce harm from unsupervised ingestions and continued education about avoiding CCM use for young children. Monitoring of CCM-related harm should continue because recommendations were updated in October 2008 to avoid the use of CCMs for children <4 years of age. [ABSTRACT FROM AUTHOR]

BACKGROUND. Adverse drug events in children from cough and cold medications have been identified as a public health issue with clinical and policy implications. Nationally representative morbidity data could be useful for targeting age-appropriate safety interventions. OBJECTIVE. To describe emergency department visits for adverse drug events from cough and cold medications in children. METHODS. Emergency department visits for adverse drug events attributed to cough and cold medications among children aged < 12 years were identified from a nationally representative stratified probability sample of 63 US emergency departments from January 1, 2004, through December 31, 2005. RESULTS. Annually, an estimated 7091 patients aged < 12 years were treated in emergency departments for adverse drug events from cough and cold medications, accounting for 5.7% of emergency department visits for all medications in this age group. Most visits were for children aged 2 to 5 years (64%). Unsupervised ingestions accounted for 66% of estimated emergency department visits, which was significantly higher than unsupervised ingestions of other medications (47%), and most of these ingestions involved children aged 2 to 5 years (77%). Most children did not require admission or extended observation (93%). CONCLUSIONS. Timely national surveillance data can help target education, enforcement, and engineering strategies for reducing adverse events from cough and cold medications among children. Engineering innovations could be particularly helpful in addressing unsupervised ingestions, which is the most frequent cause of adverse events. These innovations could be applicable to other children's medications. [ABSTRACT FROM AUTHOR]

The article discusses medication issues, particularly on the use of the bamlanivimab monoclonal antibody from Eli Lilly, heparin and hypertonic sodium chloride. Also cited are the confusing information on the administration rate of bamlanivimab, and the high possibility of error on the use of heparin and sodium chloride due to their similar packaging.

The article discusses several case reports related to medication errors occurring in anaesthesia. Topics discussed include death of a patient after a spinal anaesthetic medication error, injection of 200-mg ropivacaine via a central venous line and wrong dose medication error. Also discusses several types of medication errors including syringe swop, syringe label error and drug repackaging error, methods to prevent medication errors at management and individual level and by using technology.

The article discusses the possibility of medication errors in telephone consultations and how to avoid them by citing the case of a medical resident who ordered 50 units of insulin glargine instead of 15 units because of miscommunication with the endocrinologist. Topics include some recommendations to prevent said error like removal of mask or face shield when speaking by phone, and a case of similar drug label error.

The article presents an analysis of reports gathered by the Institute for Safe Medication Practices Medication Errors Reporting Program regarding medication errors attributed to the use of pen injectors in the United States. Pen injectors, which were primarily intended to facilitate easy and accurate self-administration of subcutaneous drugs, can now be found in hospitals and other health care settings for patient medication administration.

The article notes a recommendation by health care professionals and representatives of health systems and group purchasing organizations for bar codes on drug packaging as a way to reduce the number of medication errors by ensuring that the right medicine goes to the right patient at the right time. The Pharmaceutical Research and Manufacturers of America (PhRMA) stated it would take two years for pharmaceutical companies to implement machine-readable codes on drug products.

Presents news briefs related to medical care as of February 2001. United States Food & Drug Administration's proposal for drug package inserts to help reduce medical errors; U.S. Pharmacopeia's study of medication errors in the United States in 1999; Results of a British study on the effects of hypertension on cognitive performance. INSET: Some suggestions for treating depression in the elderly..

The article reports that the Institute for Safe Medication Practices (ISMP) has received several complaints about the packaging of levOCARNitine tablets from the pharmaceutical company Hi-Tech Pharmacal. According to the complaints, each tablet does not have its own bar code. Consumers also complained that the adverse reactions and expiration date of the drug are difficult to read.

The article focuses on several reports of medication errors. One report describes a dosage error committed by a pediatrician who sent an electronic prescription for a child to a pharmacy for Miralax powder. Another report discusses a discovery by the electronic prescribing network Surescripts that some new prescriptions for the glucagon-like peptide-1 receptor agonists Victoza and Saxenda pen injectors contain inaccurate dosage information.

The article presents medication errors that were reported to the Institute for Safe Medication Practices as of November 2017. One is the administration of Epinephrine adrenaline to a patient to induce mydriasis during intraocular surgery despite Par Pharmaceutical's removal of the mydriasis indication from the labeling. Another is a possible mix-up between two cartons of CSL Behring's AlbuRx 25 albumin due to packaging similarities.

The article looks at several medication and self-medication malpractices and errors as of February 2017. Topics covered include approval of uric acid transporter 1 inhibitor Lesinurad as a single entity tablet rather than a combination product with a xanthine oxidase inhibitor, an inexperienced nurse confused by label, and look-alike vials of vecuronium 20-milligram injection and vancomycin 1-gram injection.

The article presents cases of medication errors in the U.S. along with the suggestions on how to avoid similar events. Topics include the reference to the suggestion for adults' awareness on safe medication storage in lieu of child safety caps, incorrectly metoclopramide-stocked automated dispensing machine for use by a patient requiring megestrol as well as guard against insulin overdose through concentration checks on pens' labels prior to syringe injections.

The article discusses cases of medication errors. Topics discussed include a pharmacy technician's mistake of restocking an automated dispensing cabinet with the alpha adrenergic receptor agonist Vazculep instead of the cholinesterase inhibitor Bloxiverz, an error in the dosage of oral methotrexate for rheumatoid arthritis, and tips for avoiding medication errors.

The article presents various medication errors. It is mentioned that Precision-Dose, a repackaging company can mislead by its wrong labeling pattern on unit dose containers of acetaminophen oral suspension. One of the hospital has intended to prescribe nitroglycerin but a nitroprusside infusion is prescribed. Common over-the-counter (OTC) eye drops and nasal sprays contain an imidazoline is also mentioned.

The article provides updates on medication errors. Three medication errors were reported in Europe involving the misadministration of bortezomib which happened when intrathecal chemotherapy or another intrathecal drug was schedule on the same day and same time as I.V. bortezomib therapy. A reorganization of parenteral products placed lookalike 10 mL vials of calcium gluconate and cupric sulfate next to each other leading to 2 near-miss errors occurring almost immediately.

The article discusses medication errors news briefs. A hospital pharmacist accidentally prepared an intravenous solution of the neuromuscular blocking agent vecuronium instead of with the correct drug, valproate, which is an antiepileptic. A nurse discovered a pharmacy dispensing error which resulted from antibiotic drug labels which look very similar. The drugs were ampicillin and nafcillin. A hospital received a batch of the drug ropivacaine each with different expiration dates.

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patients condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease. [ABSTRACT FROM AUTHOR]

The article presents comments on a revised format of package insert of prescription drugs announced by the U.S. Food and Drug Administration and will take effect on June 30, 2006. There have been significant growth in the length and complexity of the product information insert since the 1980s. The revised formatting guidelines were designed to provide health professionals with clear and concise prescribing information and to reduce the number of adverse reactions resulting from medication errors. One of the proposed changes is the addition of the initial product-approval date.

The article presents information on the changes made in the packaging for hospital unit-dose Tylenol, acetaminophen, 500 mg caplets. The new label of the fever reducer includes a bar code, which is an important safety improvement. The package similarities between the two Tylenol concentrations is likely to lead to mix-ups and possible dosing errors in facilities that do not use point-of-care bar coding. The change reinforces the point that one should not rely on package color to identify a medication.

This article reports a case of about-to-happen medication error because of the identical packaging of different medicines. According to the reported case, a nurse in a longterm care facility who was about to administer eyedrops, named HypoTears PF containing polyvinyl alcohol/ polyethylene glycol 400, to a resident noticed that the clear, single-dose container she had picked up from the resident's medication drawer contained albuterol inhalation solution. The plastic container, very similar to that of HypoTears PF, had been mistakenly placed in the drawer. It is here suggested that, to prevent mix-ups like this, one has to make sure that products in similar packages are stored separately. If the product name on single-dose containers is not clearly visible, one has to ask the pharmacy to store the containers in the original outer packaging, if possible.

Presents a case in which a medication error was caused by confusing blister packs. Case of a 71-year-old woman with chronic renal failure who while under hospital treatment developed hypotension and bradycardia; Review of the medical charts which showed she was mistakenly given a generic acebutolol instead of generic amiodarone; Reasons that the blister packs of medications are often very similar; Underuse of generic drugs in France; Packaging improvements which could reduce the likelihood of serious adverse drug reactions; French agency request that companies producing generic medications modify the packaging and labeling on the blisters.

Describes errors in medicine and techniques for avoidance. Categories of medication errors provided by the National Coordinating Council for Medication Error Reporting and Prevention; Tendencies of mix-ups in verbal and written orders involving Lantus; Need for disposal boxes for used syringes; Limitations of drugs in multiple-dose packaging.

Presents a letter to the editor reporting three cases of hypermagnesemia, published in the January 27, 1989 issue of the 'Journal of the American Medical Association.'

Reports on some medication error situations on magnesium sulfate, Claritin-D and on drug packaging requirement. Magnesium sulfate administration; Difference between Claritin-D and Claritin-D 24-hour; Requirement of the Food and Drug Administration to reduce the number of iron poisoning.

Discusses the dangers of confusing packaging of medicine in drug administration. Case of a patient overdosed with lidocaine; Packaging system of lidocaine; Similarity in the color coding for different doses; Negligence of the emergency department nurse to read the label on the syringe.