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In pictures: Medicines packaging concerns shared among superintendents

One of the images shared by a pharmacy superintendent
One of the images shared by a pharmacy superintendent

Similar-looking medicines packaging has long been an issue raised by C+D readers, but which examples do pharmacy superintendents use to illustrate their concerns?

Association of Independent Multiple Pharmacies (AIMp) chief executive Leyla Hannbeck has exclusively passed to C+D a selection of images shared among pharmacy superintendents as examples of “lookalike” packaging.

Ms Hannbeck told C+D she regularly receives pictures of medicines from senior pharmacists “with the view to highlight [the issue] to others and also bring to the attention of manufacturers and relevant organisations”.

“In a busy pharmacy environment, these can lead to serious patient safety incidents,” she warned.

“I would like to reiterate the importance of separating ‘lookalike-soundalikes’ in the pharmacy and educating the whole team about how these are among the most common dispensing errors and near misses.

“I would also like to plea with manufacturers to take care when designing their packaging and make every effort to make it easier for pharmacists to not make an error,” she added.

Similar packaging can also confuse patients, who “could potentially take the wrong dose of the wrong drug when [they] receive similar-looking packaging of some of the medicines they are taking”.

Teva responds

Commenting on the images shared, manufacturer Teva UK told C+D: “We’re really proud of the award-winning packaging of our generic medicines. It aims to help reduce the risk of dispensing errors and make it easier for patients to identify the right medicine.

“The coloured circles, clear dark font and white uncluttered box are all intended to help reduce confusion over different medicines and different strengths of the same medicine.

“We always welcome feedback from both pharmacists and patients on how we can further improve and develop our packaging offer in the future,” Teva added.

The medicines images shared by superintendents







Read C+D’s guide on avoiding errors over similar packaging

What are your best tips for avoiding 'lookalike' errors?

How High?, Community pharmacist

Would have thought Superintendents had more to worry about given the woeful lack of adequately trained and experienced staff coupled with all the services we're not going to be able to provide to the level expected of us........

CAPT FX, Locum pharmacist

I can not believe the thrust of this discussion. I can not believe TEVA even have the audacity to mention their so-called award-winning packaging is something they are proud. Their packaging is the primary reason we have so many dispensing errors. The only acknowledged cases of fatal dispensing errors involved two medicines, Propranolol and Prednisolone. They were in these fancy colourful packaging where the distinction is difficult in fast-paced slave labour like the environment of Retail Pharmacy. Yet after those cases, no one ever whimpered about the culpability of this packaging. This was not reflective of the lack of blame on this, but the power which Manufacturer ownership and Pharmacy ownership have over the very patient safety issues we clamour about every day. We have been talking about this for years and we have been asking questions why our Regulator is silent about the packaging which is central to dispensing errors. We even have CPD modules called Look-alike soundalike drug errors because we are scared of these "award-winning packaging" that has caused us to lose patients. Registrants review their errors, learn from and do CPD but they return to the same old packaging that is a challenge to our poorly trained or untrained dispensing staff. Why does our Regulator, not regulate the Manufacturing Companies. It is the same question we have been asking why Pharmacy Owners are not regulated too. I read an effort which was made on this platform to highlight the Plight of Pharmacists. This effort fell flat in my opinion because it failed to acknowledge the fact that most of the work pressure is not coming from NHS cuts but from Company owners who are not regulated and can do whatever they want without penalty or censure. I have always said that the Football industry has a regulation that determines who is deemed fit to own a football club, yet Al Capone can actually own a Pharmacy, no questions asked. 

We are a laughing stock especially when we allow Teva to say their "award-winning packaging reduces dispensing errors". Off late, they have resorted to the use of cartons which you can not close when you open them once. Another award-winning innovation and do I hear the Pharmacy sheep meekly going baa or maa in a tremendous unison of approval

Mark Ashmore, Superintendent Pharmacist

Have to agree with Teva that their packaging is the best., very noticeable that in the above examples that the strengths are all different and prominent and if on a shelf are unlikely to be adjacent.

The Lorazepam/Oxazepam boxes are a perfect example of how not to design medicine packaging.

Richard Dacombe, Dispenser Manager/ Dispensing Assistant

We utilize pack scanning on all prescriptions. Labels are only produced once the correct product is selected and scanned.

Mitesh Patel, Community pharmacist

Is that unlicensed Thiamine and Calcium+Ergocalciferol I can see?

Justin Heng, Community pharmacist

Was just wondering that.. and to be a headline picture for c and d as well too

A B, Community pharmacist

I'm sure everyone fills out the relevant paperwork when dispensing these.....

Ianto Jones, Community pharmacist

The flaps on some of the teva packs don't close once opened. Likely to loose contents easily in the dispensary or by patients !

Tired Manager, Community pharmacist

After I not so nice error a few years ago I now always make a point of physically "ticking" the writing on the box as part of the accuracy check. Not quite bulletproof but it has definitely helped me! (Shout out to the customer who complained the pharmacist "drew pictures on the box" sigh...)

Leon The Apothecary, Student

FMD and automated dispensing help with accuracy checking, I think that's the future way things are going to go, at the risk of forgetting how to check "manually"

N O, Pharmaceutical Adviser

Ticking is just a confirmation, unless you actually read the name on the box and open the box (not FMD version) to make sure something else is not put inside.

Alexander The Great, Community pharmacist

Yes, i agree this does reduce some errors, however you can get into the routine of ticking the drug name without actually looking.

A.S. Singh, Community pharmacist

Numerous locums and contractors I have worked with all admit that signing boxes cause more errors. Better to sign the bag label.

N O, Pharmaceutical Adviser

LASA contributes as a major factor in dispensing errors. We may blame the Manufacturers for their stupid colour coding. But, why we never blame ourselves for not checking the print and just go with the colour??

Imagine, if we had the same kind of packaging restrictions as Cigarettes imposed on us. Which means uniform colour coding. Which means all packs look similar with the Generic Name printed at the Bottom. So, in this case who will you blame, if dispensing error happens?

So, please read the pack before dispensing.

Leon The Apothecary, Student

Garcia et al's research showed that generic labelling was far better, making all the labels uniform seem to be the best way to go for accuracy.

Lucky Ex-Locum, Superintendent Pharmacist

This is the thing though, isn't it? It has to be all or nothing. You can't have SOME of the packs being identical.

David Moore, Locum pharmacist

In my early days of pharmacy, we'd count tablets out of bulk jars. Can't ever remember packaging causing problems, and if we did inadvertently pick up the wrong pot, as soon as we saw the contents, we'd realise our mistake.
Patient packs. Progress?

Alexander The Great, Community pharmacist

'back then' when you made a mistake that had gone out, the patient would have probably taken it and be none the wiser. Now, they can actually see whats on the box.

Lucky Ex-Locum, Superintendent Pharmacist

Exactly right. There were far less errors back then when you actually had to READ the label on the tub rather than go by what the box looked like. I do agree, however, that the manufacturers do nothing whatsoever to help us out regarding packaging. It seems corporate identity is more important than patient safety.

As for the thiamine/calcium and vit D pots, any pharmacist worth their salt would be able to tell the difference the moment the pot was opened, by smell alone.

bilal hussain, Community pharmacist

I wonder how confusing that would be for patients now, considering most dispensing isn't done using bulk tubs.

I had a patient who was given folic acid and methotrexate, both from pots. She mixed the two up.

Lucky Ex-Locum, Superintendent Pharmacist

Why didn't she read the labels?

Leon The Apothecary, Student

Because as a general rule of thumb, it is safest to assume that patients will not read the label.

C A, Community pharmacist

or the information leaflet - unless there is an obscure reference to using with caution with a condition or medication they are on... in which case they'll read it and be back!

Lucky Ex-Locum, Superintendent Pharmacist

I hate information leaflets. They give people ideas.

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