Possible contributing factors and

cases of medication errors in packaging and labeling

Yu Mi Ko , Jae Youn Kim, Song Yi Moon, Yang Sook Na, ° Young Cheon Song, Hye Young Shin

Department of Pharmacy, Asan Medical Center

Medication errors are the most common cause of patient injuries in hospitals. There are different types of errors-improper dose, incorrect drug, incorrect route and so on. And the causes of errors are diverse-human factors, communication, name confusion, labeling, packaging and design, too. In this study, we especially pay attention to labeling and packaging as a contributing factor of a medication error. Few procedures exist to identify confusingly similar drug packages and defects in the labeling and packaging. So, we investigated the packaging and labeling of the drugs most frequently used during Sept. 2006 in AMC. Before the investigation, we analyzed practitioners’ reporting news in USP from 2000 to 2005 and categorized each case in accordance with the NCCMERP(National Coordination Council for Medication Error Reporting and Prevention)’s Taxonomy of Medication Errors. And then we used the categories as a measurement to evaluating packaging and labeling. Most of us have known that packaging similarities played a role in the occurrence of a medication error. But there are more flaws that we have overlooked. They need to be complemented by practitioners and manufacturers. Packaging and labeling are not considered quite important in Korea. But we must be concerned about packaging and labeling, which have a enough possibility to cause a medication error and should be changed for the better. It’s time for pharmacists to be proactive for the improvement in packaging and labeling.