Article Text

Download PDFPDF
CP-124 Multicentre, controlled study on medication safety and feasibility of single unit blister packs
  1. J Reichhold,
  2. I Kraemer
  1. Universitätsmedizin Mainz, Pharmacy, Mainz, Germany


Background In German hospitals, medicinal products are mostly distributed in the original packs to ward stocks.

Nurses remove the oral dosage forms from blister packs and dispense them into tablet boxes The system lacks means of identification and appropriate usage information Single units, where each single item of oral medicine is individually packed in a perforated multi-dose blister card and appropriately labelled, are a favourable alternative.;

Purpose To evaluate the rate of distribution errors and the rate of acceptance of single unit blister packages (SUBP) by nurses and patients.

Materials and methods In the study, dispensing of oral dosage forms by nurses with SUBP compared to conventional blister packages was evaluated in six German hospitals. The medicines observed by visual inspection were (Co)Diovan 80 mg, 160 mg, 80/12.5 mg and Amlodipine Pfizer 5 mg, 10 mg. Correct dispensing was checked. Occurrence and type of errors were documented and the error rates calculated. Acceptance by nurses and patients as well as patients’knowledge was evaluated by questionnaires.

Results 2070 dispensing events for 332 patients were analysed. The error rate was 1.8% with SUBP and 0.7% in conventional blister packages. The error rate was related to the type of ward and strength of the medicines dispensed. The risk of error was found to be different between medicines. Nurses rated SUBP as favourable and expected a lower rate of dispensing errors with SUBP. However, patient questionnaires showed an insufficient level of patient knowledge regarding their individual medicines.

Conclusions The rate of dispensing errors was not reduced when using specified medicines in SUBP instead of conventional blister packages. This result can be explained by the study design and several confounding factors. As SUBP was the preferred packaging design and patients’knowledge and responsibility were encouraged, the pharmaceutical industry is urgently requested to implement SUBP.

No conflict of interest.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.