Purchasing and Design For Patient Safety Professor David Cousins Head of Patient Safety Medicines and Medical Devices National Patient Safety Agency London.

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Presentation transcript:

Purchasing and Design For Patient Safety Professor David Cousins Head of Patient Safety Medicines and Medical Devices National Patient Safety Agency London

Design For Patient Safety Series

Council of Europe Report 2007 On Safe Medication Practice Current European medicines regulations concerning naming, packaging and labelling for pharmaceutical products provide inadequate safeguards for patients Medication errors frequently occur in Europe because of sound-alike or look-alike drug names, similarities in packaging and labelling appearance and unclear, ambiguous or incomplete label information

Council of Europe Report 2007 On Safe Medication Practice There is little recognition of the importance of the human factor principles in selection and design of drug names, labels and packages in order to minimise the potential for error and enhance medication safety The current design for labelling and packaging prioritise industry concerns, such as “trade dress”, instead of considering the context where the pharmaceutical product has to be used. It is not patient-centred, but, rather, relies on an assumption of perfect performance by healthcare professionals and by patients

Patient Safety Incident Involving Vaccines

Minimising Risks To Patients Facilitate correct actions Make it easier to discover errors and take corrective action Education, training and work competencies

Purchasing For Safety Procuring products that are safer to use in practice Meeting licensing standards is the minimum – practice standards may be higher Not always awarding the contract to the cheapest Products should meet the quality and safety specification – then procure at minimum cost Provide feedback to manufacturers to obtain safer products

Use Colour And Design

Allocate Space for a Dispensing Label

Vial Design

Differentiating Injectable Products

Look-a-like Names

Ampoule Design

Name and Strength

Bar Codes

Labelling of Ampoules and Syringes

Technical Information

Infusion Product Differentiation

Screen Display

Use of Colour and Design

Keyboard Layout

Interface Design Consistency

Use of ISO Symbols

Infusion Device Alarms

Dose Error Reduction Software

Use Of Bar Codes By Infusion Devices

The ‘Universal’ Connector

Safer Enteral Devices

Spinal (Intrathecal), Epidural And Regional Administration Of Medicines