Annette Charlton
9 Jan 2015 · Coroner Louise Hunt · Birmingham & Solihull
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. medication packaging indistinguishable
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Later report
“The Pharmacy and Nursing Matron [name redacted], concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label.”
Closely relatedConfidence 0.85 · high
This report
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Later report
“That the visual similarity of tablets of differing strengths of carbimazole to each other and to aspirin presents a risk of inadvertent overdose;”
Responses
2015-0009-Response-by-Crescent-Pharma-Limted.pdf ↗· Crescent Pharma Ltd