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Recommendations for Health Care Organizations to Reduce Medication Errors Associated with the Label, Labeling, and Packaging of Pharmaceutical (Drug) Products and Related Devices These recommendations apply to health care systems, hospital systems, individual hospitals, long-term care facilities, and other organized health care settings. The Council recommends that health care organizations employ machine-readable systems (e.g., bar coding) in the management of the medication use process. Health Care Organizations should utilize industry standards to ensure machine-readable validity meets industry quality standards The Council recommends that systematic approaches, including Failure Mode and Effects Analysis (FMEA) and root cause analysis, be implemented within the health care organization to identify and evaluate actual and potential causes of errors related to labeling and packaging. The Council recommends the development of policies and procedures for repackaging of medications that will clarify labeling to help prevent errors. The Council encourages collaboration among health care organizations, health care professionals, patients, the pharmaceutical industry, standard-setters, and regulators to facilitate design of drug product packaging and labeling to help minimize errors. The Council recommends that health care organizations develop and implement (or provide access to) education and training programs for health care professionals, technical support personnel, patients, and caregivers that address methods for reducing and preventing medication errors. Adopted: March 30, 1998 Revised: June 7, 2007 © 1998–2010 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.