The Medicines and Healthcare products Regulatory Agency (MHRA) is to review chloramphenicol eye and ear drop packaging to help prevent dispensing errors involving the drug, following a request by Pharmacy Voice.

An audit carried out by Pharmacy Voice in over 5,000 pharmacies found that there were 42 patient safety incidents involving chloramphenicol preparations in 2013. When scaled up to all pharmacies in the UK, this amounts to around 100 dispensing errors a year. Over 1.75 million chloramphenicol prescriptions are written each year in England.

Chloramphenicol ear and eye drops are particularly susceptible to incorrect selection because they have the same active ingredient, and the strengths (0.5% for eye drops and 5% for ear drops) are easily confused. Pharmacy Voice is calling for further implementation of robust procedures in community pharmacy, along with changes to the packaging of the preparations, which could help to reduce the prevalence of errors.

Rob Darracott, chief executive of Pharmacy Voice, said that while “in the vast majority of cases, pharmacy teams supply medications quickly and accurately to patients,” the data from the audit “reinforces the need for manufacturers to consider the size, shape and lettering on their packaging to help reduce these mistakes”.

In the meantime, a fact sheet of actions taken by pharmacy teams to reduce errors is available via: www.pharmacyvoice.com.