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5PSQ-211 Medication errors relating to similar or misleading manufacturer specific drug packaging and labelling
  1. M Jeske Msc1,
  2. C Gehmacher2,
  3. P Salchner1,
  4. M Zeiler1
  1. 1Innsbruck University Hospital, Pharmacy Department, Innsbruck, Austria
  2. 2Institute of Pharmacy University of Innsbruck, Pharmacology and Toxicology, Innsbruck, Austria


Background and importance Pharmaceutical packaging is often associated with medication errors. The so-called ‘lookalikes’ and ‘soundalikes’ are especially challenging. While some countries have already tackled this problem and introduced appropriate legislation, no initiatives have yet been taken in Austria.

Aim and objectives This study aimed to analyse the pharmaceutical packaging of the university hospital pharmacy’s product portfolio for similar or misleading manufacturer specific drug packaging and labelling to determine whether there are security gaps in this regard.

Material and methods The recommendations of the ‘soundalike–lookalike’ (SaLa) working group founded by Swiss hospital pharmacists were used as criteria. Also, cases of near misses reported in were evaluated.

Results 1139 secondary and 1102 primary packaging for solid oral preparations, and 474 secondary and 653 primary packaging for parenteral preparations were assessed. The main risks were in the primary packaging of parenteral products, such as no ink used to increase security (76.4%), missing specification of the total amount of active substance (32.6%) and concentration per volume (30.3%) or multiple concentration indications (16.5%). Of a total of 522 reports on CIRSmedical, 35 were relevant for the evaluation. CIRSmedical’s data confirmed the main problem with parenteral products’ primary packaging and indicated an increased risk of medication errors caused by soundalikes–lookalikes in the anaesthesia and intensive care sector. The university hospital pharmacy’s product portfolio must be regarded as a limitation of this work, as it only has a selected range of pharmaceuticals throughout Austria. A further limiting factor is CIRSmedical itself, as there is a general focus on errors, and there is no specialisation for identifying medication errors.

Conclusion and relevance Evaluation of the manufacturer’s implementation showed an inconsistent fulfilment of the recommendations of the working group SaLa and existing security gaps in the design of drug packaging. Some companies’ pharmaceutical packaging is very well thought out, while labelling on ampoules is hardly legible in others. Still, many pharmaceutical companies tend to prioritise marketing considerations when selecting the design of labels and packaging, and ignore human factors. Professionals, legislation and the pharmaceutical industry must be involved to reduce medication errors caused by misleading manufacturer specific drug packaging and labelling.

Conflict of interest No conflict of interest

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