One of my interests is potential confusion between drugs names. It is thought to be responsible for 25% of medication errors.
The BBC report on a study to be presented at the Ergonomics Society conference:
Prof Gale said: “Many tablets have unusual names which can look confusingly similar.“Medicinal packages can also be similar in shape and colour and this can cause problems, either to the consumer who might be rushing to make a purchase, or the pharmacist in selecting the pack from the shelf.
“Existing as well as new labelling and packaging designs need to be assessed appropriately to help minimise the potential for human error.”
He has now called on the industry and NHS to work together to create a more simple system.
The industry have decided to use their standard first line tactic and go on the defensive, having apparently learnt absolutely nothing about the handling of drug safety issues over the years.
But a spokesman for the Association of the British Pharmaceutical Industry said the criticisms were unfair.“Drug names are based on the clinical properties of the medicine.
“They are not marketed at patients as over-the-counter medication is.
“GPs prescribe them and pharmacists dispense them. They should not be making mistakes, they have undergone training.”
Besides being immediately dismissive of the research being discussed, they display an understanding of human error that is decades out of date.
It is instructive to compare the pharmaceutical industry with the aviation industry. Boeing have been designing planes for years. They do not design them merely to be able to overcome the force of gravity in order to lift a plane from the ground, keep it aloft and land it again.
Boeing are aware that seventy percent of commercial airplane hull-loss accidents involve human error. Rather than saying “Pilots should not be making mistakes, they have undergone training.” they have given considerable thought about how the plane will be used by pilots, and serviced by engineers. They call this Human Factors design.
The term “human factors” has grown increasingly popular as the commercial aviation industry has realized that human error, rather than mechanical failure, underlies most aviation accidents and incidents. If interpreted narrowly, human factors is often considered synonymous with crew resource management (CRM) or maintenance resource management (MRM). However, it is much broader in both its knowledge base and scope. Human factors involves gathering information about human abilities, limitations, and other characteristics and applying it to tools, machines, systems, tasks, jobs, and environments to produce safe, comfortable, and effective human use. In aviation, human factors is dedicated to better understanding how humans can most safely and efficiently be integrated with the technology. That understanding is then translated into design, training, policies, or procedures to help humans perform better.
Boeing employs human factors specialists, and has done since the 1960s. They look at cognitive psychology, human performance, physiology, visual perception, ergonomics, and human-computer interface design. They help “help humans perform to the best of their capability while compensating for their natural limitations.” So they ask “Should this dial go here?”, “Is the way this part is accessed by engineers optimal?” “If a engineer fails to perform action X, what mechanism will alert him or others?”
Like pilots, doctors and pharmacists are well-trained. I’m involved to some extent in training both groups. Like pilots, they are fallible. However, unlike the pilots the industry that supplies the tools they use refuses to accept that their products could benefit from design improvements, or the equivalent of test piloting. All they need to do is start to catch up with ideas the aviation industry has been taking on board for the past forty years. Some individual firms are making efforts, the NHS is making efforts and learning from aviation, so why the antediluvian attitudes from the offical body of the industry?
At any one time there are less people in planes in the sky, than there are people taking medicines. And almost certainly the number of people dying in plane crashes is dwarfed by those dying from medication errors. It has been suggested that the number of people dying from medication errors in the US alone is equivalent to three Jumbo jets crashing each day.
If they were Boeings, something would be done about it.