NPC Archive Item: Design for patient safety: a guide to the labelling and packaging of injectable medicines published

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Patient safety is a key priority for the NHS and is the first domain described in “Standards for Better Health”.1 The health service is a complex system where the potential for error and harm to patients is ever present. This is particularly true for medicines given that the majority of healthcare interventions involve their use.

Between January 2005 and June 2007, the National Patient Safety Agency (NPSA) received 59,000 reports of patient safety incidents involving medicines. Those involving injectable medicines accounted for 25 per cent of all the medication incidents, and 58 per cent of the most serious incidents; those that resulted in death or serious harm to the patient.2

In 2000, “An organisation with a memory3 proposed a strategy for reporting and learning from adverse events and recognised the key role that design can play in delivering safer healthcare products, services, processes and environments. The NPSA’s Design for patient safety initiative is a vital part of improving patient safety. As part of this initiative a guide to the labelling and packaging of injectable medicines4 has been published to provide guidance to facilitate safer design in healthcare

What is the background to this?
A study undertaken as part of the Design for patient safety initiative concluded that:

  • the NHS is seriously out of step with modern thinking and practice with regard to design. A consequence of this has been a significant incidence of avoidable risk and error.
  • there is little evidence of design understanding or practice within the NHS equivalent to those which are commonplace in other safety critical industries and leading commercial organisations
  • there was cause to question not simply the design of medical devices, products, packaging and information, but the way the NHS as a whole uses design in an effective way and its understanding of what design thinking can bring to an organisation
  • there are no quick fixes. On the contrary, it is of the utmost importance that single design initiatives are seen in the context of the ‘big picture’ of the healthcare system as a whole and the way it impacts on patient safety and risk management.
  • such ‘big picture’ understanding is not present and the highest priority must be attached to remedying this without delay.

Research has shown that a third of reported medication incidents may be caused by confusion over packaging and labelling.5

The National Patient Safety Agency is involved in a series of initiatives to facilitate safer design in several areas of health care. It has already published two Design for patient safety booklets that cover medicines and medicines management. These are “A guide to the design of the dispensing environment” and “A guide to the design of dispensed medicines”.

“A guide to the labelling and packaging of injectable medicines” is the latest addition to the series and provides examples of how professionals who dispense and administer medicines can put into practice the advice of Dr Keith Ridge, Chief Pharmaceutical Officer for England, on taking an overview of safe systems and how medicines are used in practice.


  • The guide covers the labelling and packaging of injectable medicines
  • In addition to commercial products, it includes those manufactured in NHS facilities and hospital pharmacies
  • It includes guidance on medicines supplied directly to patients

So what?
The design of labelling and packing of injectable medicines has the potential to reduce the number of medication errors and patient safety incidents.

Organisations, managers and healthcare workers involved in procuring, dispensing and administering medicines should use this booklet as a resource to introduce new initiatives applicable to their own disciplines to minimise harm from medicines.

Item details
NPSA (2008) Design for patient safety. A guide to labelling and packaging of injectable medicines.

1. Department of Health (2004). Standards for better health.
2. National Patient Safety Agency (2007). Safety in doses: medication safety incidents in the NHS. The fourth report from the Patient Safety Observatory. (2007).
3. Department of Health (2000), An Organisation with a Memory: Report of an expert group on learning from adverse events in the NHS The Stationery Office, London
4. NPSA (2008). Design for patient safety. A guide to the labelling and packaging of injectable medicines.
5. Berman A. Reducing medication errors through labelling and packaging. Journal of Medical Systems. 2004; 29(1): 929

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