Considering the impact of medicine label design characteristics on patient safety

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

Advantages of graphical nutrition facts label: faster attention capture and improved healthiness judgement

Consumers have to rely on the traditional back-of-package nutrition facts label (NFL) to obtain nutrition information in many countries. However, traditional NFLs have been criticised for their poor visualisation and low efficiency. This study redesigned back-of-package NFLs integrated with bar graphs (black or coloured) to visually indicate nutrient reference values (NRVs). Two eye movement studies were performed to evaluate the ergonomic advantages of the graphical NFLs. Our findings suggested that the newly designed NFLs led to faster and better healthiness evaluation performance. The newly designed graphical labels led to a shorter time to first fixation duration and offered a higher percentage of fixation time in the nutrient reference values region compared with that observed using traditional text labels. Nowadays, many chronic diseases are associated with poor eating habits, therefore, the importance of visualisation design to nudge healthier food choices could be paid more attention to by policymakers and food manufacturers.Practitioner summary: To improve the ergonomic design of traditional nutrition facts panel (NFL), this study assessed a newly designed graphical NFL. The results showed that graphical NFL captured consumers' attention faster and improved their healthiness judgement. Moreover, a brief nutrition education can improve consumers' attention and understanding of nutrition information.

Human factors in anaesthesia: a narrative review

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Interventions to Reduce Problems Related to the Readability and Comprehensibility of Drug Packages and Labels: A Systematic Review

OBJECTIVE

The aim of the study was to evaluate the effectiveness of interventions designed to reduce problems with readability and comprehensibility in drug labels.

METHODS

A systematic review of observational and experimental studies was conducted using MEDLINE (via PubMed), Embase, and Scopus databases. Two independent reviewers selected articles and collected data about study design, interventions, and outcomes.

RESULTS

Of 1786 studies screened, 17 were included in this systematic review. The main findings were described according to the type of intervention in the drug package or label: color-coded labels (7 studies); changes in information layout (5 studies); changes in font size (3 studies); and interventions involving look-alike/sound-alike (LASA) drugs (3 studies). Color changes were important both for healthcare professionals to improve safety in hospital practice and for medication users to differentiate between the types of insulin. Layout changes were effective and included highlighting key information, such as medication name, dose, and instructions. Increased font size yielded good results in the recognition and identification of medications mainly for the population with impaired vision. This review was limited by the heterogeneity of interventions and populations studied, as well as the small number of high-quality studies, which prevented meta-analysis across any one intervention or outcome.

CONCLUSIONS

All studies reported positive results for the proposed interventions. In the case of LASA drug names, the use of resources beyond Tall Man lettering (such as color and highlighting) reduced recognition errors, which may contribute to the development of new strategies to improve safety in the use of LASA drugs.

Effects of Text Enhancement, Identical Prescription-Package Names, Visual Cues, and Verbal Provocation on Visual Searches of Look-Alike Drug Names: A Simulation and Eye-Tracking Study

OBJECTIVE

Simulation and eye tracking were used to examine the effects of text enhancement, identical prescription-package names, visual cues, and verbal provocation on visual searches of look-alike drug names.

BACKGROUND

Look-alike drug names can cause confusion and medication errors, which jeopardize patient safety. The effectiveness of many strategies that may prevent these problems requires evaluation.

METHOD

We conducted two experiments that were based on a four-way, repeated-measures design. The within-subject factors were text enhancement, identical prescription-package names, visual cues, and verbal provocation. In Experiment 1, 40 nurses searched for and selected a target drug from an array of drug packages on a pharmacy shelf mock-up. In Experiment 2, the eye movements of another 40 nurses were tracked while they performed a computer-based drug search task.

RESULTS

Text enhancement had no significant effect on the drug search. Nurses selected the target drugs more quickly and easily when the prescriptions and drug packages shared identical drug name formats. The use of a visual cue to direct nurses' attention facilitated their visual searches and improved their eye gaze behaviors. The nurses reported greater mental effort if they were provoked verbally during the drug search.

CONCLUSION

Efficient and practical strategies should be adopted for designs that facilitate accurate drug search. Among these strategies are using identical name appearances on drug prescriptions and packages, using a visual cue to direct nurses' attention, and avoiding rushing nurses while they are concentrating.

APPLICATION

The findings aim to inspire recommendations for work system designs that will improve the visual search of look-alike drug names.

Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study

OBJECTIVE

Several factors contribute to medication errors in clinical practice settings, including the design of medication labels. The objective of this study was to quantify the impact of label design on medication safety in a realistic, high-stress clinical situation.

METHODS

Ninety-six anesthesia trainee participants were randomly assigned to either the redesigned or the current label condition. Participants were blinded to the study's focus on medication label design and their assigned label condition. Each participant was the sole anesthesia provider in a simulated operating room scenario involving an unexpected vascular injury. The surgeon asked the participant to administer hetastarch to the simulated patient because of hemodynamic instability. The fluid drawer of the anesthesia cart contained three 500-ml intravenous bags of hetastarch and one 500-ml intravenous bag of lidocaine. We hypothesized that redesigned labels would help participants correctly select hetastarch from the cart. If the participants incorrectly selected lidocaine from the cart, we hypothesized that the redesigned labels would help participants detect the lidocaine before administration.

RESULTS

The percentage of participants who correctly selected hetastarch from the cart was significantly higher for the redesigned labels than the current labels (63% versus 40%; odds ratio, 2.61 [95% confidence interval, 1.1-6.1]; P = 0.03). Of the participants who incorrectly selected lidocaine from the cart, the percentage who detected the lidocaine before administration did not differ by label condition.

CONCLUSIONS

The redesigned labels helped participants correctly select hetastarch from the cart, thus preventing some potentially catastrophic medication errors from reaching the simulated patient.

Users' preferences and perceptions of the comprehensibility and readability of medication labels

OBJECTIVE

To evaluate the labeling preferences of medication users and characterize their perceptions of the comprehensibility and readability of medication labels.

METHODS

We conducted a population-based cross-sectional study of medication users aged 18 years or older in 10 Brazilian capital cities. Perceptions of the comprehensibility and readability of medication labels in relation to sociodemographic characteristics were evaluated by Poisson regression models with robust variance. Labeling preferences were assessed through questions addressing possible improvements and through the use of digitally simulated packages.

RESULTS

Of 6,255 medication users interviewed, more than half found it difficult or very difficult to read (50.8%) and/or understand (52.0%) medication labels. Difficulties were more pronounced for participants aged 40 years or older, with lower levels of education, and non-whites. Increasing the font size (93.7%), describing the indications for use (95.9%) and contraindications (95.6%) on the label, and highlighting the expiration date (96.3%) were the most widely accepted improvements. In the evaluation of simulated packages, users preferred factors that improved readability, such as increased font size, use of graphic elements and color to highlight the concentration of the active ingredient, and contrast between the font color and background. The new simulated package design, with increased font size, color to highlight the concentration and contrast between the font color and background, was preferred over the standard design by 77.0% of participants.

CONCLUSION

Based on users' perceptions, increased font size and use of graphic elements and color to emphasize critical information, such as expiration date and concentration, are factors that contribute to making medication labels clearer to users. Pharmaceutical industries and policy makers should consider these items when developing labels and defining policies on this issue.

Assessment of primary labeling of medicines manufactured by Nepalese pharmaceutical industries

Background

Appropriate labeling of marketed medicines is necessary to fulfill the regulatory provisions and ensure patient medication safety. This study aimed to assess the primary labeling of medicines manufactured and marketed by Nepalese pharmaceutical industries.

Methods

We assessed the primary labeling of all medicines available at the pharmacy of Chitwan Medical College Teaching Hospital (CMCTH), Chitwan, Nepal, between November 2017 to December 2017. Medicines were assessed as required by Drug Standard Regulation, 2043 (1986 AD) of Nepal. Appropriate classification of all the medicines and content of over-the-counter (OTC) medicines (where certain information should be in Nepali language) was also assessed. Descriptive statistics was performed.

Results

Seven hundred fifty-nine medicines manufactured by 37 Nepalese pharmaceutical industries were assessed. While all pharmaceutical products had the name of the drug (brand), only76.8% of them stated drug quantity. Almost all products were found to declare category of the drug, with only a few (4.1%) mentioning the sub-category. The system of medicine was stated in 9.9% of the products. Active ingredients and their quantity, manufacturer’s information, serial number for the production of drug and the date of production, storing methods, and information on the quantity used were mentioned in almost all the products. Similarly, all the products had batch number and the date of expiry. But, 11% of the products lacked the name of pharmacopoeia to which the drug belongs and all the products lacked the serial number for establishment of pharmaceutical industry. Similarly, 5.3% of the products did not list their price, and 2.4% of prescription medicines lacked caution labeling. Unfortunately, the majority of the products (84.4%) did not provide the directions of use. Appropriate drug classification was found in 89.6% of products. None of the over-the-counter medicines totally adhered to the requirements for writing certain information in Nepali language.

Conclusions

Majority of the products did not meet the regulatory standards of primary labeling of Nepalese pharmaceutical products. This study highlights the necessities for improvement from all stakeholders.

Pharmacists' training to improve inhaler technique of patients with COPD in Vietnam

Background

Incorrect use of inhalers is very common and subsequently leads to poor control of COPD. Among health care providers, pharmacists are in the best position to educate patients about the correct use of inhaler devices.

Objective

The objective of this study was to evaluate the impact of pharmacist-led training on the improvement of inhaler technique for COPD patients in Vietnam.

Patients and methods

For this pre- and post-intervention study, standardized checklists of correct use of metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) were used to evaluate the inhaler technique. A scoring system (maximum score =8) was applied before and after training to guarantee assessment uniformity among pharmacists. Three methods including "face-to-face training", "teach-back" and "technique reminder label" were used. After the baseline evaluation (T0), the inhaler technique was reassessed after 1 month (T1), 3 months (T2), 6 months (T3) and 12 months (T4).

Results

A total of 211 COPD patients participated in the study. Before the training, a high rate of errors was recorded. After the training, the percentage of patients using MDIs and DPIs perfectly increased significantly (p<0.05). The mean technique score for MDIs and DPIs improved from 6.0 (T0) to 7.5 (T3) and 6.9 (T4) and 6.7 (T0) to 7.6 (T3) and 7.2 (T4), respectively (p<0.05). The average training time was 6 minutes (T0) and 3 minutes (T3), respectively.

Conclusion

Pharmacist-led comprehensive inhaler technique intervention program using an unbiased and simple scoring system can significantly improve the inhaler techniques in COPD patients. Our results indicated a 3-month period as the optimal time period between training and retraining for maintaining the correct inhaler technique. The training would be highly feasible and suitable for implementing in the clinical setting. Our model of pharmacist-led training should be considered as an effective solution for managing COPD patients and better utilization of health care human resources, especially in a developing country like Vietnam.

Influence of drug colour on perceived drug effects and efficacy

A drug's physical characteristics, such as colour, could be factors influencing its therapeutic effects. It is not well understood whether people's expectations on drug effects and efficacy are affected by colour, especially among Chinese population. This study was conducted to examine people's expectations on drug effects and efficacy on the basis of drug colour, and to reveal possible gender differences in colour-related drug expectations. Participants (n = 224) were asked to classify seven single-coloured and six two-coloured capsules into one of four categories of drug effects, and to indicate the strength of drug efficacy. It is found that all the coloured capsules yielded non-chance distributions in classifications of drug effects, with six single-coloured and four two-coloured capsules associated with specific drug effects. Colour also conveyed differential strengths of drug efficacy in general and in relation to specific drug effects. There were gender differences in drug expectations for some colours and colour combinations. Practitioner Summary: Drug colour was found to have impacts on perceived drug effects and efficacy. The findings from the present study can be used by ergonomics practitioners to design appropriate drug colours in support of drug differentiation, therapeutic effects and medication adherence.

Adverse Events and Over-the-Counter (OTC) Drugs: Is Inappropriate Labeling the Problem? - The Case of Acetaminophen

Incorrect use of acetaminophen that results in severe liver injury is among the most common adverse drug events (ADEs) in the United States of America (USA), and other countries around the world. Compared to any other drug, it is also on the top for emergency calls, emergency room visits, and acute liver failure in the USA. Consequently, regulating acetaminophen has become a heated and unresolved public debate. During the last decades, multiple efforts have taken place to address the issue, mostly focused on the premise that inappropriate labeling is a leading cause of such ADEs, for failure in communicating the associated risks through warnings. Unlike previous studies, this paper illustrates the importance of considering human factors principles. Three different warning labels were designed and evaluated. The results showed no statistically significant effect, despite the application of best practices for label warning design. Non-design factors, the warning process and why a warning could fail are also illustrated. Implications could help researchers, policy makers, and manufacturers to consider focusing less on traditional labeling interventions, and to invest efforts more systematically considering also the current trends and the current needs of consumers.

User Evaluation of Neonatology Ward Design

Objective:

The object of this article is to identify the set of affective and emotional factors behind users’ assessments of a space in a neonatology unit and to propose design guidelines based on these.

Background:

The importance of the neonatology service and the variety of users place great demands on the space at all levels. Despite the repercussions, the emotional aspects of the environment have received less attention.

Methods:

To avoid incurring limitations in the user mental scheme, this study uses two complementary methodologies: focus group and semantic differential. The (qualitative) focus group methodology provides exploratory information and concepts. The (quantitative) semantic differential methodology then uses these concepts to extract the conceptual structures that users employ in their assessment of the space. Of the total 175 subjects, 31 took part in focus groups and 144 in semantic differential.

Results:

Five independent concepts were identified: privacy, functionality and professional nature, spaciousness, lighting, and cleanliness. In relation to the importance of the overall positive assessment of the space, the perception of privacy and sensations of dominance and pleasure are fundamental. Six relevant design aspects were also identified: provide spacious surroundings, facilitate sufficient separation between the different posts or cots, use different colors from those usually found in health-care centers, as some aversion was found to white and especially green, design areas with childhood themes, use warm artificial light, and choose user-friendly equipment.

Conclusions:

Results provide design recommendations of interest and show the possibilities offered by combining both systems to analyze user response.

Evaluating the application of research-based guidance to the design of an emergency preparedness leaflet

Guidelines for the design of emergency communications were derived from primary research and interrogation of the literature. The guidelines were used to re-design a nuclear emergency preparedness leaflet routinely distributed to households in the local area. Pre-test measures of memory for, and self-reported understanding of, nuclear safety information were collected. The findings revealed high levels of non-receipt of the leaflet, and among those who did receive it, memory for safety advice was poor. Subjective evaluations of the trial leaflet suggested that it was preferred and judged easier to understand than the original. Objective measures of memory for the two leaflets were also recorded, once after the study period, and again one week or four weeks later. Memory for the advice was better, at all time periods, when participants studied the trial leaflet. The findings showcase evaluation of emergency preparedness literature and suggest that extant research findings can be applied to the design of communications to improve memory and understandability.

STATEMENT OF RELEVANCE

Studies are described that showcase the use of research-based guidelines to design emergency communications and provide both subjective and objective data to support designing emergency communications in this way. In addition, the research evaluates the effectiveness of emergency preparedness leaflets that are routinely distributed to households. This work is of relevance to academics interested in risk communication and to practitioners involved in civil protection and emergency preparedness.

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use

BACKGROUND

Chemotherapy is an effective treatment in the fight against many cancers. Medication errors in oncology can be particularly serious given the narrow therapeutic window of antineoplastic drugs and their high toxicities. Computerized prescriber order entry (cpoe) has consistently been shown to reduce medication errors and adverse drug events in various settings, but its use in the oncology setting has not been well established. To gain a better understanding of the meaningful use of cpoe systems in the outpatient chemotherapy setting, we undertook a systematic review of systemic therapy cpoe.

METHODS

A province-wide expert panel consisting of clinical experts, health information professionals, and specialists in human factors design provided guidance in the development of the research questions, search terms, databases, and inclusion criteria. The systematic review was undertaken by a core team consisting of a medical oncologist, nurse, pharmacist, and methodologist. The medline, embase, cinahl, and compendex databases were searched for relevant evidence.

RESULTS

The database searches resulted in 5642 hits, of which 9 met the inclusion criteria and were retained. In the oncology setting, cpoe systems generally reduce chemotherapy medication errors; however, specific types of errors increase with the use of cpoe. These systems affect practice both positively and negatively with respect to time, workload, and productivity.

CONCLUSIONS

Despite the paucity of oncology-specific research, cpoe should be used in outpatient chemotherapy delivery to reduce chemotherapy-related medication errors. Adoption by clinicians will be enhanced by cpoe processes that complement current practice and workflow processes.

The legibility of prescription medication labelling in Canada: Moving from pharmacy-centred to patient-centred labels

INTRODUCTION

The legibility of medication labelling is a concern for all Canadians, because poor or illegible labelling may lead to miscommunication of medication information and poor patient outcomes. There are currently few guidelines and no regulations regarding print standards on medication labels. This study analyzed sample prescription labels from Ontario, Canada, and compared them with print legibility guidelines (both generic and specific to medication labels).

METHODS

Cluster sampling was used to randomly select a total of 45 pharmacies in the tri-cities of Kitchener, Waterloo and Cambridge. Pharmacies were asked to supply a regular label with a hypothetical prescription. The print characteristics of patient-critical information were compared against the recommendations for prescription labels by pharmaceutical and health organizations and for print accessibility by nongovernmental organizations.

RESULTS

More than 90% of labels followed the guidelines for font style, contrast, print colour and nonglossy paper. However, only 44% of the medication instructions met the minimum guideline of 12-point print size, and none of the drug or patient names met this standard. Only 5% of the labels were judged to make the best use of space, and 51% used left alignment. None of the instructions were in sentence case, as is recommended.

DISCUSSION

We found discrepancies between guidelines and current labels in print size, justification, spacing and methods of emphasis.

CONCLUSION

Improvements in pharmacy labelling are possible without moving to new technologies or changing the size of labels and would be expected to enhance patient outcomes.

Exploring the perspectives of potential consumers and healthcare professionals on the readability of a package insert: a case study of an over-the-counter medicine

PURPOSE

To explore and compare the opinions of physicians, pharmacists and potential users on the readability of a package insert of an over-the-counter medicine.

METHODS

Exploratory study based on the administration of a semi-open questionnaire. This instrument was developed according to the readability guideline of the European Medicine Agency (EMA) and used to evaluate participants' accessibility to, and comprehensibility of, the package insert for diclofenac 12.5 mg tablets. Sixty-three participants were recruited from the Lisbon region and enrolled in three groups: physicians (Dg), pharmacists (Pg) and potential consumers (PCg), with a minimum of 20 participants each.

RESULTS

Almost all (85 %) of the 20 PCg participants were educated above the 9th grade, although the majority of them (95 %) referred to, at least, one package insert interpretation issue, mainly related to the comprehension of technical terms. Amongst other differences between the groups, the Pg participants (n = 22) obtained a significantly less favourable opinion regarding the layout of the titles. Furthermore, the Pg and Dg (n = 21) participants proposed technical enhancements, such as the use of a table to explain the posology, precautions in case of renal failure, or the recommendation to take the tablets with meals.

CONCLUSIONS

Differences in the way of using the diclofenac tablets are expected, considering the comprehension dissimilarities between health professionals and potential consumers. The package insert of diclofenac 12.5 mg could be enhanced for safer use. Regarding the readability assessment of this package insert, the method proposed in the EMA guidelines might not be as effective as expected. Future research is advisable.

The effect of proximity, Tall Man lettering, and time pressure on accurate visual perception of drug names

OBJECTIVE

The aim of this study is to assess the effect of proximity and time pressure on accurate and effective visual search during medication selection from a computer screen.

BACKGROUND

The presence of multiple similar objects in proximity to a target object increases the difficulty of a visual search. Visual similarity between drug names can also lead to selection error. The proximity of several similarly named drugs within a visual field could, therefore, adversely affect visual search.

METHOD

In Study 1, 60 nonpharmacy participants selected a target drug name from an array of mock drug packets shown on a computer screen, where one or four similarly named nontargets might be present. Of the participants, 30 completed the task with a time constraint, and the remainder did not. In Study 2, the same experiment was repeated with 28 pharmacy staff.

RESULTS

In Study 1, the proximity of multiple similarly named nontargets within the specified visual field reduced selection accuracy and increased reaction times in the nonpharmacists. Time constraint also had an adverse effect. In Study 2, the pharmacy participants showed increased reaction times when multiple nontargets were present, but the time constraint had no effect. There was no effect of Tall Man lettering.

CONCLUSION

The presence of multiple similarly named medications in close proximity to a target medication increases the difficulty of the visual search for the target. Tall Man lettering has no impact on this adverse effect.

APPLICATION

The widespread use of the alphabetical system in medication storage increases the risk of proximity-based errors in drug selection.

Consumer perceptions of medication warnings about driving: a comparison of French and Australian labels

OBJECTIVE

Little research has examined user perceptions of medication warnings about driving. Consumer perceptions of the Australian national approach to medication warnings about driving are examined. The Australian approach to warning presentation is compared with an alternative approach used in France. Visual characteristics of the warnings and overall warning readability are investigated. Risk perceptions and behavioral intentions associated with the warnings are also examined.

METHOD

Surveys were conducted with 358 public hospital outpatients in Queensland, Australia. Extending this investigation is a supplementary comparison study of French hospital outpatients (n = 75).

RESULTS

The results suggest that the Australian warning approach of using a combination of visual characteristics is important for consumers but that the use of a pictogram could enhance effects. Significantly higher levels of risk perception were found among the sample for the French highest severity label compared to the analogous mandatory Australian warning, with a similar trend evident in the French study results. The results also indicated that the French label was associated with more cautious behavioral intentions.

CONCLUSION

The results are potentially important for the Australian approach to medication warnings about driving impairment. The research contributes practical findings that can be used to enhance the effectiveness of warnings and develop countermeasures in this area. Hospital pharmacy patients should include persons with the highest level of likelihood of knowledge and awareness of medication warning labeling. Even in this context it appears that a review of the Australian warning system would be useful particularly in the context of increasing evidence relating to associated driving risks. Reviewing text size and readability of messages including the addition of pictograms, as well as clarifying the importance of potential risk in a general community context, is recommended for consideration and further research.

Environmental issues related to medication errors in long-term care: lessons from the literature

OBJECTIVE

Medication errors contribute significantly to patient morbidity and mortality and are associated with a considerable cost to the healthcare system. The purpose of this study was to conduct a review and synthesis of the literature on the effect of physical and organizational aspects of the environment on medication and nursing errors in long-term care environments.

METHODS

Extensive database searches were conducted for relevant publications. In total, 46 empirical and 19 nonempirical (descriptive and conceptual) journal articles, books, book chapters, and reports were analyzed.

RESULTS

Environmental variables related to medication and nursing errors are: lighting/illumination, noise, inefficient layout or use of space, disorganized medication storage or administration areas, look-alike or sound-alike drugs, and equipment.

CONCLUSIONS

A supportive physical environment is important to reduce factors that may directly or indirectly contribute to errors. Both physical and organizational environments need to be addressed for an effective intervention to reduce medication and nursing errors.

Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby

BACKGROUND

Reports regarding hand hygiene compliance (HHC) among hospital visitors are limited. Although there is an implicit assumption that the availability of alcohol-based hand sanitizer (AHS) promotes visitor HHC, the degree of AHS use by visitors remains unclear. To assess AHS use, we observed visitor HHC and how it is affected by visual cues in a private university hospital.

METHODS

Using an observational controlled study, we tested 3 interventions: a desk sign mandating all visitors to use AHS, a free-standing AHS dispenser directly in front of a security desk, and a combination of a freestanding AHS dispenser and a sign.

RESULTS

HHC was 0.52% at baseline and did not improve significantly when the desk sign was provided as a cue 0.67% (P = .753). However, HHC did improve significantly with use of the freestanding AHS dispenser (9.33%) and the sign and dispenser combination (11.67%) (P < .001 for all comparisons of dispenser alone and sign and dispenser with baseline and sign alone). The degree of improvement with the sign and dispenser combination over the dispenser was not statistically significant.

CONCLUSIONS

Hospital visitors represent an important factor in infection prevention. A coordinated effort is needed to increase visitor HHC, including an evaluation of the AHS placement, education of visitors on the importance of HHC, and evaluation of corresponding changes in hand hygiene behavior.

Standardised drug labelling in intensive care: results of an international survey among ESICM members

PURPOSE

Standardised coloured drug labels may increase patient safety in the intensive care unit (ICU). The rates of adherence to standardised drug syringe labelling (DSL) in European and non-European ICUs, and the standards applied are not known. The aim of this survey among ESICM members was to assess if and what standardised drug syringe labelling is used, if the standards for drug syringe labelling are similar internationally and if intensivists expect that standardised DSL should be delivered by the pharmaceutical industry.

METHODS

A structured, web-based, anonymised survey on standardised DSL, performed among ESICM members (March-May 2011; Clinicaltrials.gov NCT01232088). Descriptive data analysis was performed and Fisher's exact test was applied where applicable.

RESULTS

Four hundred eighty-two submissions were analysed (20 % non-European). Thirty-five percent of the respondents reported that standardised drug labelling was used hospital-wide, and 39 % reported that standardised DSL was used in their ICU (Europe: Northern 53 %, Western 52 %, Eastern 17 %, Southern 22 %). The International Organization of Standardization (ISO) 26825 norm in its original form was used by 30 %, an adapted version by 19 % and local versions by 45 %; 6 % used labels that were included in the drug's packaging. Eighty percent wished that the pharmaceutical industry supplied ISO 26825 norm labelling together with the drugs.

CONCLUSIONS

Standardised DSL is not widely applied in European and non-European ICUs and mostly does not adhere strictly to the ISO norm. The frequency and quality of DSL differs to a great extent among European regions. This leaves much room for improvement.

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

OBJECTIVE

Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems.

DESIGN

A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task.

MEASUREMENTS

The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems.

RESULTS

Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04).

CONCLUSIONS

Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes.

The contribution of labelling to safe medication administration in anaesthetic practice

The administration of medications is central to anaesthetists' care of patients. Errors are inevitable in any human endeavour, but should be distinguished from violations. The incidence of medication errors in anaesthesia has been estimated as 1 per 13,000 administrations, excluding errors in recording. Adverse medication events follow a proportion of these errors. Labelling is a key element of medication safety. There is a long-standing need for improvements in the labelling of ampoules and vials. An international standard exists for labelling syringes used during anaesthesia (ISO 26825). Australia has recently released national recommendations for labelling lines and injectable medications that complement this and other relevant standards. The provision of at least some medications in pre-filled syringes would reduce the number of steps involved in medication administration, increase the certainty that syringe labels are correct and probably reduce medication errors. Pre-printed, peel-off flag labels on ampoules and vials are a less expensive alternative to pre-filled syringes to facilitate correct labelling. The medication name on user-applied labels should be matched to that on the relevant ampoule or vial at the time of drawing up any medication. All lines and catheters should be labelled. Any medicine or fluid that cannot be identified (e.g., in an unlabelled syringe or other container) should be considered unsafe and discarded. Reducing adverse medication events will require the engagement of individual anaesthetists.

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names

Visual errors in the perception of written drug names can reflect orthographic similarity amongst certain names. Drug names are typically printed in lowercase text. 'Tall Man' lettering, the capitalisation of the portions that differ amongst orthographically similar drug names, is employed in the field of medication labelling and prescribing to reduce medication errors by highlighting the area most likely to prevent confusion. The influence of textual format on visual drug name perception was tested amongst healthcare professionals (n = 133) using the Reicher-Wheeler task. Relative to lowercase text, Tall Man lettering improved accuracy in drug name perception. However, an equivalent improvement in accuracy was obtained using entirely uppercase text. Thus, character size may be a key determinant of perceptual accuracy for Tall Man lettering. Specific considerations for the manner in which Tall Man lettering might be best formatted and implemented in practice to reduce medication errors are discussed. STATEMENT OF RELEVANCE: Tall Man lettering aims to prevent medication errors by reducing visual confusions amongst orthographically similar drug names. It was found that, compared to lowercase text, Tall Man lettering improved accuracy in drug name perception. Character size appeared to be a key determinant of perceptual accuracy for Tall Man lettering.

Key components of intravenous chemotherapy labeling: A systematic review and practice guideline

Objective. To determine the necessary components and formatting of an intravenous chemotherapy label to maximize safe delivery and minimize errors.

Date sources. The MEDLINE and EMBASE databases (up to April 2009) were searched for relevant evidence. Reference lists from retained studies were then searched for additional trials. An environmental scan was also conducted to locate other published and unpublished sources of information.

Study selection. Relevant articles were selected and reviewed by one methodologist. Articles were selected for inclusion if they were published English language reports of Phases II or III randomized controlled trials, other comparative studies, single-arm studies, practice guidelines, or systematic reviews with or without meta-analyses, which related to the study question. MEDLINE and EMBASE searches yielded 685 potential studies of which 17 met the inclusion criteria. The environmental scan located one guideline. Three additional relevant studies were identified during the external review process. In total, 21 documents met the inclusion criteria.

Data extraction. Data were extracted by one methodologist. Quality of systematic reviews was assessed using the AMSTAR tool. All other studies were evaluated based on study characteristics applicable to the particular study design.

Data synthesis. The evidence collected and the consensus of expert opinion of Cancer Care Ontario’s Chemotherapy Labeling Panel form the basis of a series of recommendations for the generation of intravenous chemotherapy labels including formatting, required information, and order of information. These guidelines inform the efficient, effective, and safe administration of intravenous chemotherapy. Illustrative examples are provided.

Reading the small print - labelling recommendations for orthopaedic implants

INTRODUCTION

There exist, currently, no clear guidelines regarding standards for surgical implant labelling. Dimensions of the laminar flow canopies in orthopaedic use fixes the distance at which implant labels can be read. Mistakes when reading the label on an implant box can pose health risks for patients, and financial consequences for medical institutions.

SUBJECTS AND METHODS

Using scientifically validated tools such as the Snellen Chart Formula, a theoretical minimum standard for text on implant labels was reached. This theoretical standard was then tested under real operating conditions. After discovering a minimum practical standard for implant labels, the authors then audited current labels in use on a wide range of orthopaedic implant packages. Furthermore, other non-text-related labelling problems were also noted.

RESULTS

There is a definite minimum standard which should be observed when implant labels are manufactured. Implants in current use bear labels on the packaging that are of an insufficient standard to ensure patient safety in theatre.

CONCLUSIONS

The authors have established text parameters that will increase the legibility of implant labels. In the interests of improving risk management in theatre, therefore, the authors propose a standard for orthopaedic implant labelling, and believe this will provide a useful foundation for further discussion between the orthopaedic community and implant manufacturers.

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

Alerts and prompts represent promising types of decision support in electronic prescribing to tackle inadequacies in prescribing. A systematic review was conducted to evaluate the efficacy of computerized drug alerts and prompts searching EMBASE, CINHAL, MEDLINE, and PsychINFO up to May 2007. Studies assessing the impact of electronic alerts and prompts on clinicians' prescribing behavior were selected and categorized by decision support type. Most alerts and prompts (23 out of 27) demonstrated benefit in improving prescribing behavior and/or reducing error rates. The impact appeared to vary based on the type of decision support. Some of these alerts (n = 5) reported a positive impact on clinical and health service management outcomes. For many categories of reminders, the number of studies was very small and few data were available from the outpatient setting. None of the studies evaluated features that might make alerts and prompts more effective. Details of an updated search run in Jan 2009 are included in the supplement section of this review.