Guidance for the Design of Unit Dose Drug Labels

Issue
University Health Network (UHN) recently purchased a new unit dose drug packaging machine for the Toronto General site. The new machine allows for greater flexibility in the display of information on the unit dose label. The pharmacy department wanted to format the new labels in a way that would reduce the potential for errors. The Healthcare Human Factors Group was asked to provide guidance on the general format of the labels based on principles of typography, human factors engineering, guidance documents and standards and an understanding of the workflow of all clinicians that use the information on the labels.

Methods
A detailed review of current literature related to the design of safe medication labels was conducted. Concurrently, a task and workflow analysis of the central pharmacy environment was conducted to understand the information needs and information flow throughout the system. This resulted in an understanding of how unit dose drug label information is generated and used, and the potential sources of error that exist as a result of unit dose drug labels in the central pharmacy.

Results
This work is still in progress. The literature review has provided a useful background for general principles that should guide label design. A task and workflow analysis of the nursing environment with respect to the administration of unit dose drugs will provide the remaining information necessary to develop prototype labels that will be usability tested.