The design of pharmaceutical products, packaging, information and related materials is a major source of human error. These errors may be stressful, harmful or even fatal. Given the scale of the problems and the global use of medication, design solutions are urgently needed. This paper in Applied Ergonomics demonstrated how such improvements can be made, drawing on research that investigated how the design of methotrexate packaging can influence patient safety.
The project, undertaken in light of a number of serious incidents in the UK resulting from accidental overdoses of methotrexate, aimed to collect evidence to provide a basis for the development of new concepts for revised designs by the pharmaceutical industry. Buckle et al. found that patients using methotrexate experience a number of difficulties in using their medicine’s packaging and, as a result, resourcefully adopt a variety of ‘coping strategies’ which may increase the risk of dosing errors. By investigating both the practices of methotrexate users, and the design of the system that supports methotrexate use, additional problems were observed across the healthcare system, meaning that the function of medicines packaging in ensuring safety may be even more critical than first suspected.
Buckle contributed to this paper through the derivation of a suitable human-factors approach to studying fatalities, errors and ‘near misses’ associated with the use of packaging for medications. The human factors (human behaviour) associated with these and the need to consider the whole system were essential elements provided by Buckle in the research.
As a result of the research project, the National Patient Safety Agency responded with a UK-wide programme of work to improve safety for patients, and continues to work with the pharmaceutical industry to develop more user-friendly packaging and labelling.