First reported 9 Jan 2015•Latest report 2 Jun 2024
Definition
What this concern includes
Includes failures in the design, labelling, colour differentiation or other dedicated identification controls for medication packaging and dispensing containers where inadequate distinction can cause the wrong medicine or patient's medication to be selected, dispensed or used.
Not included
Excludes medication prescribing, administration, reconciliation and supply failures where packaging or dispensing-container identification is not the deficient control.
Excludes general product labelling or medication warnings that do not concern distinguishing medicines or patients' medication containers.
Excludes patient-identification failures unrelated to medication packaging or dispensing-container differentiation.
Excludes generic dispensing, pharmacy or manufacturing deficiencies unless they directly create inadequate visual or other identification of medication packaging.
Reports
4
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2015–2024
First to latest report issue date
Stated actions
11
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Medicines and Healthcare products Regulatory Agency4
Department of Health and Social Care2
General Pharmaceutical Council2
Community Pharmacy England1
Community Pharmacy Thames Valley1
Crescent Pharma Limited1
National Pharmacy Association1
NHS England1
NHS Frimley Integrated Care Board1
NHS Specialist Pharmacy Service1
Northern Care Alliance NHS Foundation Trust1
Nursing and Midwifery Council1
Royal Pharmaceutical Society1
Slough Pharmacy1
Medicines and medical devices regulator4
Health and care professional regulator3
Ministerial department2
Executive non-departmental public body1
Healthcare site1
Health professional body1
Health-sector membership body1
Integrated care board1
NHS provider group1
NHS trust1
Private limited company1
Professional membership body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Berkshire
Concerns raised1
Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Consider adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.
Stated by NHS Specialist Pharmacy ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Review existing guidance and consider refinements for supporting patients with cognitive impairments.
Stated by National Pharmacy AssociationStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Raise the risk of confusing multi-compartment aids in one household with the Royal Pharmaceutical Society and request consideration of additional guidance or information.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Raise the risk of confusing multi-compartment aids in one household with the Community Pharmacy Patient Safety Group and request consideration of additional guidance or information.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Inform represented community pharmacy owners about the risk of confusing multi-compartment aids in one household.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Double-check each tray with the patient after removing it from packaging.
Stated by Wexham Road pharmacyStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
Action
Provide differently branded trays with distinct packaging to households where multiple people use trays.
Stated by Wexham Road pharmacyStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.9
Position
Community pharmacies are independent contractors under a national framework, limiting the ICB’s direct influence over their processes.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Different dosette or label colours are not currently available because legal labelling requirements limit community pharmacy options.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Pharmacy dispensing concerns fall outside the medicines regulator’s remit, which covers medicines placed on the UK market.
Stated by MHRA Customer Experience CentreOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about pharmacists’ dispensing actions should be addressed to the General Pharmaceutical Council, the pharmacy and pharmacist regulator.
Stated by MHRA Customer Experience CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for labelling dispensed medicines lies with the regulator, so the service does not provide labelling information.
Stated by NHS Specialist Pharmacy ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Dispensing medication is governed by a national pharmacy contract agreed and negotiated nationally, rather than by the local pharmacy committee.
Stated by Thames Valley LPCOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for commissioning dispensing medication rests with Frimley ICB, which has raised the matter with NHS England.
Stated by Thames Valley LPCRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Community pharmacies operate as independent contractors under national contracts, limiting direct influence over their processes.
Stated by NHS Frimley Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Different dosette or label colours are not currently available because community-pharmacy dosettes must meet legal labelling requirements.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Suffolk
Concerns raised1
Insufficiently distinctive packaging and visual identification of intravenous fluids for arterial line transducer sets
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Consider improvements with the marketing authorisation holder to make statutory information easier for clinical staff to assimilate and reduce selection errors.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 23 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Colour cannot be used in IV-fluid labelling because container manufacturing prevents it; other local risk controls are required.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Because Viaflo containers cannot use colour differentiation, local clinical areas must implement other measures to identify intravenous fluids correctly.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised1
Phosphate Polyfusor product design failing to distinguish the medication clearly
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Ensure nursing staff recognise different Polyfusor products and check all medication details in full.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Birmingham and Solihull
Concerns raised1
Almost identical medication boxes
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Meet with the MHRA to discuss packaging redesign and colour differentiation between products and strengths.
Stated by Crescent Pharma LimitedStated plannedThe respondent said that this action was planned when they made their response on 9 January 2015.
Action
Revise product artwork to minimise pharmacist dispensing errors caused by failure to verify product identity.
Stated by Crescent Pharma LimitedStated plannedThe respondent said that this action was planned when they made their response on 9 January 2015.
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Includes failures in the design, labelling, colour differentiation or other dedicated identification controls for medication packaging and dispensing containers where inadequate distinction can cause the wrong medicine or patient's medication to be selected, dispensed or used.
