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Research into medication error and supply chain issues led to the creation of a risk management tool to be used by GSK in the design and implementation of medical packaging.
Intranet site for GSK
This design study created a risk management tool to be used in the design and implementation of medical packaging. Lack of compliance, miscalculation of doses and prescription errors can lead to an increase in hospital admissions and fatalities. Medication errors increase dramatically amongst older people and packaging design needs to accommodate this demographic shift in order to impact positively on patient safety. Working with pharmaceutical company GlaxoSmithKline, this project aimed to directly improve design practice within the company.
The project began by exploring current practice to understand the complexity of the pharmaceutical global supply chain. New product development processes were looked at to see how pack demands can influence any new design. The project then focused on immediate patient safety issues with face-to-face visits, interviews and recorded observations. Research areas included use of the pack in the home, on a hospital ward, and in the pharmacy. This research revealed generic problems encountered by staff such as similar-sounding names, illegible type and confusing use of colour.
The risk management tool consists of a website which takes the user through the three scenarios of home, ward and pharmacy. For each scenario, the series of tasks involving the pack are described, with an outline of possible errors at each stage. For each error, the causes and effects are listed. Where the cause is poor design, pictorial examples of offending packs are listed, along with recommendations for design improvements. The tool also contains concept packs designed as a response to the outlined medical errors. Two of the concepts were prototyped and are displayed alongside the tool.
