What’s wrong with drug packaging?

pharmacist in dispensary

Life would be so much easier—and safer—if drug packaging was designed with pharmacists in mind, writes Angelo Pricolo

Sometimes we walk around the dispensary looking at things and wonder why they are so. Pretty deep for a pharmacist.

So many drugs are not packaged in pharmacy friendly ways. Where do we begin! It makes us wonder if pharmacists ever have any input before the drug hits the shelf. If they did I’m sure it would not just benefit the pharmacist but ultimately improve patient outcomes and costs.

How hard is it to get the safety seal off an antibiotic mixture? But one company has put a little tab on the seal so without the aid of a device (that you can never find when you need it) one can simply peel off the barrier and reconstitute the powder.

Maybe some of us are showing our age but with regard to those antibiotic mixtures, could they make the font any smaller? Surely the volume needed to add to the powder could be made a little clearer.

A significant proportion of dispensing errors occur due to inadequate manufacturer labelling. This is a compelling statement in anyone’s language.

Drug companies love to follow a theme with their products to reinforce the brand. Unfortunately this often adversely impacts on the very products they are selling and we are dispensing. There are so many examples where two packs of the same molecule look identical except for the strength of the drug. This can be such a subtle difference that making a dispensing error over time is almost inevitable.

The same can be said for different dose forms. Cream or ointment can easily be interchanged when the labelling does not distinctly differentiate the two products. From a pharmacist’s point of view we need different colours and designs to clearly assist recognition of strengths and dose forms. Conversely, not providing this really only increases the likelihood of the error taking place.

It is easy to say we should be more careful but we all know human error can always creep in. Why would anyone not want to minimise this risk? Manufacturers, big pharma, generic companies…. Please read and act on this plea!

Lots of pharmacists are getting a bit frustrated with Cautionary and Advisory Labels (CALS). Wouldn’t it be a great world where the drug company complied with requirements and agreed with regulators to include the CAL on the box? If the box also left a space for the dispense label the CAL could be positioned appropriately. Everybody wins!

The other annoying habit by some manufacturers is labelling to ensure a product sits on the shelf in a particular orientation. That is it encourages, even ensures, the product has maximum exposure or shelf space. This is understandable but still frustrating for front-of-shop products but totally unacceptable in the dispensary. These drugs need identifiable labelling on as many facings as possible to minimise the possibility of errors.

Although we all understand the importance of the trade name for marketing purposes, the generic name of the drug is also very important. Whether it’s a pharmacist dispensing or a patient checking their drug, especially with the explosion of generics, this is a safety issue.

Drug companies are always trying to ensure they have superior products to their competitors. They compete on price but often disregard factors that make a difference to the pharmacist and the end user. The more energy put into these considerations and maybe a little less on self-serving ventures could go a long way to building a reputation rather than alienating a customer.

Angelo Pricolo is a National Councillor with The Pharmacy Guild of Australia and a member of the PSA Harm Minimisation Committee.

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  1. pagophilus

    Good to see this issue being discussed. It needs to come to the forefront.
    What is the point of drawing a box and writing “affix label here” in it when that box is the wrong size and shape for a label?

  2. james jefferies

    How about every time a dispensing error comes before the board that can be reasonably attributable (at least in part) to poor manufacturer packaging the manufacturer gets a mandatory $100k fine? I’m pretty sure that a few fines might get the industry to up its game.

    • Leah Rosevear

      Good idea and yes the often non-pharmacist friendly packaging is a huge concern, especially in these days in such busy working environments.

  3. Tony Pal

    I have worked 24 years in hospital, 3 years in retail and over 12 years in industry. I understand where you are coming from and there many limitations to what manufacturers can do with packaging. It would be lovely to have space for a dispensing label on everything but how big a tube or eye drop bottle do you want and what will the excessive headspace (oxygen) do to product stability. Colours are a problem as there are only so many high contrast colours that are legible, or readily recognisable when comparing in hurry. In fact similar colours & similar packaging cause there own ‘product mix-up’ issues. One answer is to have everything exactly the same in plain black text on white box to force people to read the label. Family branding can be both good and bad. Compared to everything as black & white boxes, it helps you to select product quicker because the branding comes to mind readily and easily, then you narrow down to product, strength and pack size. Slow down as your selection narrows and breath in the effort the company has gone to with infinite subtleties. Believe it or not companies do receive and take seriously ‘look alike’ complaints. Feel free to speak up and complain, and don’t forget to make the facts clear, even offer suggestions. Also accept the fact that sometimes despite infinite variety, if that were possible, at some point you do have to stop and read the label, that no amount of secondary identifiers take the place of reading the label.
    Regarding small text, there is only so much space, and there is mandated text required by the TGA. Do you prefer to look up the PI instead? Safety seals – I love the idea of them being easier to get off, but the companies problem is getting them to stay on 100% with all seals, all of the time and no exceptions. It is embarrassing explaining to someone in a hot humid climate that they have to throw the packet away because the seal falls off in a moist environment. Sometimes redesigning an already available tamper evident seal is not cost effective, unless you are really keen to offer to pay more, and in a generic market, it is a race to the bottom for cost effectiveness. So off-the-rack seal it is and yes I have been there with a full dispensary struggling with an antibiotic mixture trying to remove the seal, and I means all of the seal, confirm correct volume and repeat the effort many times over in the shortest possible time, which is never fast enough.
    Get a job with a manufacturer and have a go designing packaging and labelling yourself. Surprisingly it is a good job and industry could use some clever out of the box thinking that is practical, complies with the manufacturing process, the TGA and is cost effective. (PS: I have written this as an experienced pharmacist and not as a company representative.)

  4. AD

    2D barcodes should be mandatory.

  5. Marvin Clark

    Good designs reduce costs and improve durability; rising energy and paper costs make eco-friendly packaging more appealing to the pharmaceutical industry because of its cost efficiency. Read more at http://www.mobilak.co.il

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