Article Text

Download PDFPDF
PS-036 Risks and inefficiencies in hospitals caused by inadequate packaging of oral medications
  1. A Rossignoli1,
  2. E Villamañán2,
  3. C Lara2,
  4. M Ruano2,
  5. E Pérez2,
  6. M Moro2,
  7. E Rodríguez2,
  8. M Moreno2,
  9. M Molina2,
  10. A Herrero2
  1. 1La Paz University Hospital, Madrid, Spain
  2. 2La Paz University Hospital, Pharmacy, Madrid, Spain


Background Lack of adequate packaging of oral solid medications is an important source of inefficiency in hospitals. There are drugs marketed by pharmaceutical companies in blister-packs where identification data appear printed for a group of pills rather than each one, a requisite for inpatients. This inadequate labelling requires the pharmacy to repackage them, leading to waste of time. This process generates new potential medication errors because repackaged pills look similar, making it easy for healthcare professionals to confuse them with one another.

Purpose To evaluate the extent to which drugs prescribed to inpatients were manipulated in hospitals because of their inadequate marketed presentation. Wastage in the process of adequate medication trade-dress was evaluated, as was the proportion of look-alike repackaged drugs.

Material and methods A prospective longitudinal study was carried out (14 days) in a tertiary hospital. Pharmacotherapy prescribed to adult patients was evaluated daily (410 beds). Using a CPOE programme, pharmacists checked the number of repackaged look alike drugs dispensed to these patients on a daily basis. Moreover, we checked the number and time consumed in repackaging.

Results Pharmacotherapy of 4199 inpatients was analysed. 2000 received at least one repackaged pill. Admitted patients received a total of 3336 repackaged look alike drugs. Specialties most frequently involved were internal medicine (73.3% of their inpatients) and haematology (70.7%). On the other hand, a total of 13 758 units were repackaged in the pharmacy service which meant that 983 media (SD±600) of look-alike medications were generated in the pharmacy every day. According to data registered in the pharmacy, it takes 4.9 s on average to repackage 1 pill (approximately 80 min were wasted daily). Over the study period, a dispensing error related to look alike repackaged pills occurred because of confusion in their storage.

Conclusion There is a high rate of inadequately marketed oral medications being dispensed to inpatients. Medications marketed in blister packs require individual pills to be repackaged by pharmacy services, leading to a waste of time. Moreover, this process may constitute a hazard to patient safety, increasing medical errors by confusion. Drug regulatory agencies should promote standards for packaging and labelling of drugs individually identified to improve safety and efficiency in the medication use process in hospitals.

References and/or acknowledgements Pharmacy staff.

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.