Mobile camera as an aid to minimize drug errors

Human errors are the most common cause of drug errors.¹ The National Coordinating Council for Medication Error Reporting and Prevention defines medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.² Product labeling is one of the several factors that may contribute to such events. A drug label carries information about its composition, recommended mode, and route of administration, manufacturing and expiry date. To avoid the errors in drug administration, it is strongly recommended that the label on any drug or ampoule or syringe should be carefully read and checked with a second person before a drug is drawn up or injected. Similar packaging and presentation of drugs should also be avoided wherever possible.³

Standard specifications exist for labels for small-volume (100 mL or less) parenteral drug containers. The standard provides recommendations for the color, size, design, general properties and typographical characteristics of the labels. It also states that the font size should be as large as possible to aid readers. A size of 9 points, as measured in ‘Times New Roman’, not narrowed, with a space between lines of at least 3 mm, is the minimum for the packet leaflet. User testing, meant to test the readability of a specimen with a group of selected test subjects, is also advocated. The American Society of Anesthesiologists has also amended its statement on creating labels of pharmaceuticals for use in anesthesiology. But we could not find similar literature on ampoules. Several ampoules carry information which is difficult to read by naked eye (Figure 1A). This becomes especially important for ampoules that are looking similar as they carry potential of drug being administered wrongly.⁴ One solution to the problem is to use a magnifying glass to read it but this would necessitate carrying one during practice. Mobile phones are now routinely carried by everyone. Hence an easy and feasible alternate is to have a photograph of the ampoule with the mobile camera and zoom to read it (Figure 1B). The photo could easily be shared with others to have it cross-checked by several persons simultaneously, and any discrepancy in judgment can be resolved. It will also provide complete details at single glance unlike several adjustments required with the magnifying lens (Figure 1C). The image quality will undoubtedly depend on the pixels of camera but it will definitely be an aid to naked eye examination.

Figure 1
A, Image of ampoule taken while keeping at convenient distance; B, Zoomed mobile image of the same ampoule; C, Ampoule’s label as visible through a magnifying glass.

Acknowledgement

Authors acknowledge Dr. Anamika Purohit for technical assistance in preparing the manuscript and Mr. Satyanarayan Tripathi for digital art work.

References

• ¹
  Kothari D, Gupta S, Sharma C, Kothari S. Medication error in anaesthesia and critical care: A cause for concern. Indian J Anaesth. 2010;54:187-92.
• ²
  The National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP: The First Ten Years ‘Defining the Problem and Developing Solutions’; 2005. p. 4.
• ³
  Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth. 2010;105:76-82.
• ⁴
  Paliwal B, Purohit A, Sethi P. Apnoea during Spinal Anesthesia: A Medication Error. Karnataka Anaesth J. 2016;2:37-8.

Publication Dates

• Publication in this collection
  24 May 2021
• Date of issue
  Mar-Apr 2021

History

• Received
  2 Oct 2020
• Accepted
  29 Nov 2020