Designing packaging to support the safe use of medicines at home.

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.