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eye-dropsOctober 29 2014

Research into the dispensing incidents where chloramphenicol eye drops and ear drops are mixed up has prompted an agreement to review packaging.

Over 1.75 million chloramphenicol prescriptions were written in 2013 in England. Pharmacy Voice, which represents pharmacy owners, says that extrapolated data indicates there were around 100 incidents where there was confusion over the eye drops and ear drops.

Problems arise due to the similarity in name and the strengths of the products increasing the risk of selecting the wrong product: eye drops are available 0.5% solution, while ear drops are available at 5%. There are also 10% ear drop preparations and 1% eye ointments.

Products are also kept refrigerated where there is less space to keep products well-separated, and the packaging and vessels used are similar in size, shape and colour.

“The risks associated with topical chloramphenicol preparations have long been recognised and yet incidents continue to persist with these liquid preparations,” says Pharmacy Voice. It is calling for “further implementation of robust procedures in community pharmacy coupled with changes to the packaging of the medications which could help to reduce the prevalence of this incident.”

In its report on research into chloramphenicol dispensing incidents, it says: “Given the similarity in the name of the product because of the same active ingredient, and the similar looking strength (0.5% versus 5%); there is opportunity for the incorrect selection of the product as a result of the similarity between the preparations. While this is a well-known risk, dispensing incidents continue to occur with chloramphenicol in primary care.”

As a result of its research into the problem, Pharmacy Voice says it has “secured agreement from the Medicines and Healthcare products Regulatory Agency (MHRA) to carry out a packaging review of chloramphenicol eye drops and ear drops to help reduce dispensing incidents associated with these products.”

The research was based on data collected from 5,464 pharmacies in England, from large and smaller regional multiples. This revealed 42 incidents involving topical chloramphenicol preparations, equivalent to a rate of one incident per year for every 130 pharmacies. Scaling this up to the 12,000 pharmacies across the UK, it is estimated around 1,000 such incidents happen annually.

While collating the incident reports, Pharmacy Voice has compiled shared learning from errors involving chloramphenicol eye or ear drops. Among the points made are:

•    share all dispensing incidents on a monthly basis and ask each branch to review and take steps to ensure similar mistakes are not made
•    review SOPs and ensure the team are all aware of the process required when dispensing medication
•    ask GP surgeries to review prescribing systems if instructions for ear drops usage are being put incorrectly on prescriptions for eye drops
•    clearly mark the storage area with various highlighting and separation techniques
•    do not put prescription labels over important information on the bottle
•    countersign the information on the product, label and prescription to show the right formulation has been selected, and have a second member of staff check whenever possible

Link:

Pharmacy Voice statement (includes links to downloads for research and shared learning

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