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Press releases 2006
Independent research reveals patient safety benefits of packaging across medication provision process
4 September 2006
Almus Pharmaceuticals announces the findings of a unique patient safety study which provides an insight into the use and benefits of pharmaceutical packaging throughout the medication provision process, including warehouse, pharmacy and patient. Conducted by the Universities of Surrey and Cambridge, an 'Ergonomics Study into the Effects of Packaging on Dispensing Systems and Patient Safety', is an independent piece of research, commissioned by Almus Pharmaceuticals. The research is part of a programme of patient safety initiatives to address the challenges of reducing medication error.
"The insight provided by this independent piece of research reveals significant benefits and future potential of the Almus® packaging design for a wide variety of user groups. We are in a unique position to investigate the full lifecycle of the product with research findings demonstrating considerable scope beyond the original project. The results offer a 'stakeholder-centric' evidence base for the potential development of innovative solutions to patient safety problems that can impact the entire medication provision system," says Tony Foreman, CEO of Almus Pharmaceuticals and Director of Commercial Affairs, Alliance Boots.
Taking a systems approach, researchers studied products, people, technology and their interactions. The study observed activities in context, undertaking a risk analysis of each task and highlighting the benefits of packaging, plus areas of weakness within the wider system of medication provision.
Pharmacy Findings
The Almus® pack design was found to be most beneficial in community pharmacy, in several areas identified as 'high risk' by pharmacists and dispensing technicians including:
- Initial sorting of the delivery (RPN 18-27)
- Placement of medications in the storage area e.g. carousel, shelf, dispensing system (RPN 12-18)
- Locating and picking of products when dispensing (RPN 12)
- Verification of correct medication when adding a pharmacy label
Wide variation in practice was observed throughout the course of the study. This was found to compromise safe use of medication and negate the positive benefits of the Almus® packaging, for example, pharmacy labels covering important information, and environmental factors including overcrowded workbenches and interruptions to the dispensing process.
Patient Findings
Research conducted among multiple medication users found this group to be extremely vigilant and compliant, adapting their practices to manage problems which may compromise their safety.
The detailed illustration of medication on Almus® packaging was found to be extremely helpful for patients as a final check when taking medication at home - patients find tablets easy to confuse, especially once removed from the blister.
Factors found to compromise patient safety included:
- PIL - technical, confusing information, removed from packaging with the majority storing the PIL separately
- Medication labelling - obscuring essential information with patients rewriting key details
- Blisters - poor differentiation and difficulty in removing tablets with packaging retained to aid identification
- MDS - disparity in quality between a home and pharmacy-prepared MDS was revealed to have safety ramifications
- Storage of medicines - remembering to take medication was a common problem with patients improvising storage of medications in a variety of locations around the home
Warehouse Findings
The key benefit of the Almus® packaging was at the 'put-away' stage in both automated and manual facilities, due to the easier visual identification and subsequent efficiency in processing.
Assisting users and learning surrounding error recovery activities, Almus® was also identified as an example of 'resilience engineering' , allowing errors to be more easily detected and preventing errors relating to customer orders.
The research team found that the Almus® packaging design carries substantial benefits at each stage of the distribution and usage system. However, the systems approach undertaken throughout the project has provided further insights and opportunities for improvement of the medication provision process.