The National Patient Safety Agency (NPSA) reviews medication errors on an ongoing basis, and prioritises the production of guidance and recommendations based on the level of harm reported to its Reporting and Learning System (RLS), other national and international reporting systems and published literature.
The Agency has also produced a series of design guides in the ‘Design for Patient Safety’ series, which aim to improve the labelling, and packaging of pharmaceutical products. A copy has been placed in the Library. These have been issued to pharmaceutical companies to assist them produce products that minimise the risk of miss-selection and other patient safety incidents. These materials are also used by national health service (NHS) medicines procurement groups to purchase products which are safer in use. A design guide on The Dispensing Environment which identifies ways that good design of the dispensing environment can help improve the accuracy of the dispensing process has also been produced by the NPSA.
The Medicines and Healthcare products Regulatory Agency (MHRA) has, as part of an European Union-wide action on two specific immunosuppressant therapies, agreed to send a ‘dear Doctor/Healthcare Practitioner letter’ to the relevant NHS staff, and made proposals for changes to the packaging for Advagraf to emphasise that it differs from Prograf. In addition, MHRA included the issue in their December edition of the Drug Safety Update, with a further article in the January 2009 edition. These should help to make prescribers, pharmacists, and patients aware of the brand being prescribed, whatever the manufacturer, and the associated dose regimen. MHRA has also highlighted the issue to other information providers, including the British National Formulary and the National Prescribing Centre.