I have been a pharmacist for more than 50 years, and in that time relatively few changes have been made to the clear or amber containers used to dispense tablets and capsules. One exception was the addition of safety (child-resistant) caps in the 1970s. Except for adding the name of the drug, the contents on the labels used for these containers also have been fairly consistent. The biggest changes have been in the methods used to generate the labels (ie, computer printing) and in the amount of information presented to the patient on the labels.
Now that I am older, less aware, taking several prescription drugs myself, and plagued with presbyopia, I have developed a sharper, more personal interest in the labeling. My wife is having similar visual and cognitive problems, and, despite all my years in pharmacy, we have had a number of close calls. Unfortunately, many drugs resemble one another and have similar-sounding names. Thus, it was with keen concern that I attentively watched a CBS television show one Sunday morning when a new prescription drug-packaging system was unveiled to the public for the first time. I was intrigued, and I wondered why all of the improvements cited had never occurred to me.
Causes of medication errors can include all of the following: patients with advanced age, diminished vision, memory lapses, or language issues; jammed medicine cabinets; other household members also taking prescription drugs; lack of patient counseling; containers that look alike, with too many stickers, some too small with no flat surfaces, some uncapped; and labels with crowded or unreadable type.
As a result, much has and is being done to reduce tragic drug errors. The Institute for Safe Medication Practices is devoting a great deal of effort in this area. This group has worked with the US Pharmacopeia Medication Errors Reporting Program and with the FDA's MedWatch to help ascertain the causes of medication errors. These experts have found that packaging and labeling problems are among the major causes. One individual has stepped forward to address the problems.
Deborah Adler, a graphic designer, is responsible for the impending change in prescription packaging that has been introduced as the ClearRx system at Target pharmacies. She was inspired to develop a new labeling system after her grandmother accidentally swallowed pills meant for her grandfather. Adler determined that the drugstore prescription bottle was both unattractive and actually dangerous. According to the results of a recent poll conducted for Target, Adler was correct. It appears that 60% of prescription drug users have taken medication incorrectly.
Through her research, Adler found that each pharmacy uses containers with a different style and placement of information. (This is another reason why patients should not shop for prescriptions at several different drugstores.) The drug name can appear at the bottom or at the top of the label, for example. The name of the pharmacy and its address can appear just about anywhere and usually are presented in the largest type size. The most important information often is subordinated. Color-coded warning labels frequently do not contrast strongly enough with either the bottles or the text. Several of such labels on the container may be confusing and thus may be disregarded.
Most existing prescription containers have no flat surfaces and are often too narrow for an entire label to be visible at once. The container must be rotated to observe all pertinent information. Type size frequently is very small so as to include all of the required information. Patient package inserts frequently are provided separately and thus generally are discarded, unread.
The New Labeling and Package
Adler's ideas are evident in Target's new container. The name of the drug is printed on the top, so that it is visible if the bottle is kept in a drawer. The bottle is red?the universal sign for caution and Target's signature color. The label is divided into primary and secondary positions, separated by a horizontal line. The most important information (drug name, dosage, instructions) is placed above the line, and less critical information (quantity, doctor's name, expiration date) is positioned below the line. There are 6 colored rings that attach to the neck of the bottle for family members to choose from to help prevent mix-ups. A card with more detailed information about the drug can be tucked behind the back label. A separate, expandable patient education sheet has 3 holes so that it can be saved in a binder for reference.
Adler even considered Spanish-speaking patients and has avoided the word "once" on the label, as it means "11" in that language. Warning labels have been redesigned for clarity and are printed in the "Cautions" section of the back label. This method eliminates the use of individual warning labels that often hide important prescribing information.
Together with labeling changes, Target has unique containers for pills and liquids. They are upside-down versions that stand on their caps?an ergonomically shaped design conceived with the collaboration of Klaus Rosburg. Rosburg is a renowned industrial design engineer who has developed medication packages, dispensers, and dosage systems for a number of leading pharmaceutical companies. The containers are extrusionblow- molded in a unique process and are made from a form of polyethylene. The color of the containers provides protection from ultraviolet light. Because the container is flat, labels can be wrapped around the top. There is a cap designed to be childproof but easier for adults to open. The combination of new labels and packaging are a decided improvement over contemporary methods.
The new ClearRx system from Target should be the impetus for other companies to be innovative and to improve their labeling and packaging for prescription drugs. This change is certain even though drugstores are faced with ever-diminishing margins because pharmacy benefit managers are on the scene. There is no question in my mind that pharmacies can do a better job in disseminating information, and Adler and Target should be lauded for pointing out this problem and taking action. The US Surgeon General also has reacted; on April 28, 2005, he called the new design a simple yet important step in improving the health literacy of all Americans.
Despite the fact that labeling is improving, there is still no substitute for the advice of the pharmacist. Patients also must be willing to assume an active role in their own health care.
Mr. Sherman is president of Sherman Consulting Services, Inc.
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