click to view image
Research Associates 2007
Sally Halls, RCA Industrial Design Engineering
Patient safety is often compromised by confusion over the graphic information on drugs packaging. Injectable medicines are particularly susceptible to medical error. This study gives design guidance to make such packs safer.
Design can have a significant impact on patient safety, especially the packaging and labelling of medication. According to the National Patient Safety Agency (NPSA), a National Health Service body with a specific remit to reduce medical errors, nearly ten per cent of all adverse medical incidents reported in 2004/5 involved medication. Of these, a quarter involved injectable medicines - a hugely disproportionate number given that only a small minority of medication is given via injection.
The term 'injectable medicines' refers to drugs that come in ampoules, vials, prefilled syringes and infusion bags. Whilst there are a number of factors that affect the incidence of error, one study has estimated that a third of incidents are caused by confusion over packaging and labelling. This project in partnership with the NPSA set out to investigate how better graphic design principles might reduce confusion and enhance patient safety in the primary packaging of injectable medicines. The study followed an earlier project on graphic guidance for the packaging of oral medication, also undertaken by the RCA Helen Hamlyn Centre with the NPSA.
The research looked at problems with existing designs, which are caused primarily by an emphasis on promoting the company brand so that all drugs are packaged in the same corporate livery. Key user information printed in small font sizes is then overshadowed by the corporate branding, making different drug packs virtually indistinguishable from each other.
The researcher worked closely with a user group of healthcare staff at all levels - from nurses and pharmacists to anaesthetists and procurement managers - to discover how medicines are stored, prescribed, dispensed and administered. The aim was to establish what information was vital for staff to be able to give the medication safely. In this instance, the term 'user' does not extend to the patient, who has no direct interaction with the drug packaging. A patient receiving medication via injection is likely to be very ill and may not even be conscious.
Findings from the user study were then distilled into separate design points. Each formed an illustrated double-page spread in a publication intended to be a best practice guide capturing key graphic principles of designing safer packaging. Many of the points are overarching and relate to all forms of injectable medicines, such as emphasising the generic drug name rather than the brand name. However some are only applicable to a particular form of primary packaging (the vessel that holds the drug). For example, small cylindrical ampoules will have very different requirements to large flat infusion bags. Thus each packaging form has its own section relating to its information design.
In addition to the guidelines, the publication presents exemplary packaging designs, creating solutions that can be implemented in the near future. The use of emerging technologies (such as 2D data matrix codes) are also recommended, in order to prepare pharmaceutical companies for future requirements. The booklet is aimed at packaging designers and pharmaceutical firms, as well as being a reference guide for those involved in NHS procurement.
