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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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Design For Patient Safety Series
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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
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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
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Patient Safety Incident Involving Vaccines
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Minimising Risks To Patients Facilitate correct actions Make it easier to discover errors and take corrective action Education, training and work competencies
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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
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Use Colour And Design
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Allocate Space for a Dispensing Label
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Vial Design
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Differentiating Injectable Products
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Look-a-like Names
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Ampoule Design
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Name and Strength
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Bar Codes
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Labelling of Ampoules and Syringes
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Technical Information
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Infusion Product Differentiation
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Screen Display
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Use of Colour and Design
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Keyboard Layout
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Interface Design Consistency
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Use of ISO Symbols
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Infusion Device Alarms
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Dose Error Reduction Software
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Use Of Bar Codes By Infusion Devices
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The ‘Universal’ Connector
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Safer Enteral Devices
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Spinal (Intrathecal), Epidural And Regional Administration Of Medicines
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http://www.nrls.npsa.nhs.uk
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