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Petitioning MHRA

Standardise drug packaging in the operating theatre

We believe the packaging of medications supplied to operating theatres within the UK (and around the world) needs a complete overhaul and is a matter of patient safety requiring urgent attention. 

 

Drug errors in the operating theatre are an important issue. To quote the Royal College of Anaesthetists and Association of Anaesthetists in Great Britain and Ireland in their recent 5th National Audit Project “Hospitals should take ampoule appearance into account to avoid multiple drugs of similar appearance”. This is not happening. 

 

The estimated rate of drug errors in an anaesthetic is quoted between 1 in 140 and 1 in 300. However, there is real potential that this is a gross underestimate. The cost of such errors in terms of morbidity and financial loss to healthacre systems around the world runs into the thousands of extra days in hospital and millions of pounds. Every and any opportunity to minimise the rate of drug errors must be employed. 

 

There are many elements to a drug error in the operating theatre. Which drug to use, the correct drug selection from their storage area, the preparation/dilution and then finally delivery. We believe there is much scope to improve the drug selection element. I would like to draw your attention to the diagram attached. These are potentially fatal drugs if confused. I am sure you can see how similar they appear and are surprised by it. This is one example of many.  

 

We believe that drug packaging (which includes the external box, the vial holder and the vial) should be standardised so that no matter who the manufacturer is, the appearance of a particular drug is consistent, the colouring of the class is fixed and such labelling become a national standard. Failure to adhere to this standard would mean non-compliant drugs would be banned within a theatre complex.

 

There is an existing colour coded system that is used to label syringes after the drug has been drawn up. This may be an excellent starting point on which to base the system. 

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