Unsafe naming, labelling and packaging of medicines

4 Nov 2013 | Medication Safety

The International Medication Safety Network (IMSN) recognises unsafe medicine naming, labelling and packaging as an ongoing global threat to patient safety which requires a collaborative approach. Medication errors affect millions of patients globally, sometimes leading to death or serious harm. Frequent causes of preventable errors include:

  • sound-alike or look-alike medicine names
  • similarities in packaging and labelling appearance
  • unclear, ambiguous or incomplete medicine label information.

In many countries, medicine regulation fails to recognise the importance of safe design and human factors in the selection and design of medicine names, labels and packaging.

The IMSN has released a position statement on making medicine naming, labelling and packaging safer, and recommends the following as part of a comprehensive, worldwide solution:

  1. Regulations for medicines naming, labelling and packaging in all countries should be strengthened to:
  • require safer design and field testing before release for use
  • incorporate human factors theory
  • promote safer use in practice.
  1. The pharmaceutical industry should ensure that their products are safely named, labelled and packaged to minimise errors in selection and use.
  1. Healthcare providers should assess medicines names, labels and packages, as well as associated devices and software, before purchasing decisions are made and products are introduced into use, so that risks may be identified and mitigated.

At the Safer Naming, Labeling and Packaging of Medicine Conference in October 2013 Dr Michael Cohen, chairperson of the IMSN, proposed that regulators and other stakeholders join IMSN at a summit in 2014 to address this global threat to patient safety.

About IMSN: The IMSN is an international network involving medication safety organisations, and medication safety experts and advocates. Established in November 2006 by the ‘Salamanca Declaration to Promote Safe Medication Practices Globally’, IMSN aims to prevent patient harm globally by promoting safe medication practices and collaboration between everyone involved in the medication use process. For more information visit their website: www.intmedsafe.net.

Last updated 06/11/2013