Engineering Design Centre, Engineering Department, University of Cambridge, Trumpington Street, Cambridge CB21PZ, UK.
Appl Ergon. 2010 Sep;41(5):682-94. doi: 10.1016/j.apergo.2009.12.005. Epub 2010 Feb 12.
In the light of a number of serious incidents in the UK resulting from accidental overdoses of methotrexate, this study investigated how the design of methotrexate packaging can influence patient safety, and aimed to collect evidence to provide a basis for the development of new concepts for revised designs by the pharmaceutical industry. The research found that patients using methotrexate experience a number of difficulties in using their medicines packaging, and as a result, resourcefully adopt a variety of "coping strategies" which may increase the risk of dosing errors. By investigating both the practice of methotrexate users, and the design of the system that supports methotrexate use, additional problems were observed across the healthcare system, meaning that the function of medicines packaging in ensuring safety may be even more critical than first suspected. As a result of this research the National Patient Safety Agency responded with a UK-wide programme of work to improve safety for patients, and continues to work with the pharmaceutical industry to develop more user-friendly packaging and labelling.
鉴于英国发生了多起因甲氨蝶呤意外过量服用而导致的严重事件，本研究旨在探讨甲氨蝶呤包装的设计如何影响患者安全，并收集证据为制药行业开发新的修订设计理念提供依据。研究发现，使用甲氨蝶呤的患者在使用其药品包装时遇到了一些困难，因此灵活地采用了各种“应对策略”，这可能会增加用药错误的风险。通过调查甲氨蝶呤使用者的实践和支持甲氨蝶呤使用的系统设计，还观察到整个医疗保健系统存在其他问题，这意味着药品包装在确保安全方面的功能可能比最初怀疑的更为关键。该研究结果促使英国国家患者安全局针对提高患者安全性开展了一项全英范围的工作方案，并继续与制药行业合作开发更便于用户使用的包装和标签。
