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"Lookalike" Drug Packaging

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Drug makers must think about different packaging | IndyStar.com

Here's a picture of the two drugs that were mixed up when the three babies were killed at the hospital in Indianapolis last week.

As the MD wrote in the letter-to-the-editor that I've linked to above, the deaths were absolutely preventable. We can't just blame the drug maker. This was a systemic problem. The “system” killed the babies.

The packages, to me, are hardly “identical.” Similar yes, but not identical. The MD recommends that the manufacturer put the drugs in different sized bottles. That might be a decent step, and the extra cost to the manufacturer (stocking and producing different sized bottles) would be worth it.

Maybe stronger dosed drugs/pills should always be in larger bottles/packages, denoting “stronger.” That might increase the inventory costs throughout the supply chain (more space taken up by larger packaging), but pharmacies I've seen typically have their shelves somewhat lightly utilized, at least in one direction (e.g., the shelves are packed from left to right, but they're not using vertical space well, or the shelves aren't close enough together). Pharmacies are hardly efficiently “cubing out” their stock space the way a lean manufacturer might tweak their warehouse or truck utilization. If they were really concerned about that, they would use SQUARE or rectangular bottles (ala Fiji Water — look at how these bottles “cube out” nicely in boxes and shipping containers).

Anyway, this was a systemic problem with many root causes, all of which can be fixed using lean methods. The manufacturer — change the packaging (an error proofing method). The hospital needs to take steps — error proofing and standard work among the pharmacy techs and nurses to truly prevent the problems, not just to catch the problems in time or at the last minute before drugs are given to a patient.

I've read about how the hospital is putting in more “double checks.” This is just more inspection. We need more prevention. 100% inspection isn't 100% effective. Having TWO people inspect anything (an engine built n a factory or drugs dispensed in a hospital) is sometimes WORSE than having one person inspect. Basic human psychology says we slack off if we think someone else will catch our mistake. Two inspectors might each think “well, the other person will catch it” and then nobody catches the problems.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus. His next book, to be released in 2018, is Measures of Success.

1 Comment
  1. […] the 2nd picture for the new packaging — see how much harder it would be to make a mistake? People knew about the look-alike packaging problem in 2006. Why didn’t Cedars Sinai take more preventative action before this problem occurred in late […]

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