Assessing medication packaging and labelling appropriateness in Sri Lanka

Outer packaging labelling of medicines in Southern African Development Community (SADC) countries: comparative analysis of requirements and transition terms for harmonisation

INTRODUCTION

The COVID-19 pandemic highlighted an urgent need for harmonised requirements for the regulation of medicines. To fully implement harmonised medicines regulations across Africa, common technical standards of medicine regulations are needed. One such technical standard is the labelling of medicines on outer packaging. In this study, we compared outer packaging labelling requirements and transition terms for harmonization for countries in the Southern African Development Community (SADC) region.

METHODS

Data on legislation and/or regulatory guidelines for medicine outer packaging labelling from National Medicines Regulatory Authorities (NMRAs) were obtained for countries in the SADC region (n = 16) by February 2023. A detailed comparative content analysis was conducted to determine alignment with the requirements of the Southern African Development Community (SADC) harmonised labelling guidelines to assess readiness levels of each country to transition to the SADC harmonised labelling guideline for outer packaging of medicines.

RESULTS

Content analysis showed at least 11 out of 16 countries require national legal reform to transition to the SADC harmonised labelling guideline. In all cases where countries specified labelling requirements for outer packaging of medicines, these were stipulated in national medicines legislation.

CONCLUSION

Even though there is a high level of alignment across the countries in terms of national labelling requirements, most countries in the SADC region would still require national legislative reform to transition to regional harmonised labelling requirements and then ultimately to continental requirements of the African Medicines Agency (AMA).

Knowledge and practices of private pharmacy auxiliaries on malaria in Abidjan, Côte d'Ivoire

BACKGROUND

The emergence of resistance to artemisinin derivatives in Southeast Asia constitutes a serious threat for other malaria endemic areas, particularly in Côte d'Ivoire. To delay this resistance, the application of the control measures recommended by the National Malaria Control Programme (NMCP) for a correct management, in the private pharmacies, is a necessity. The purpose of this study was, therefore, to assess the level of knowledge and practices of private pharmacy auxiliary in Abidjan about the management of malaria.

METHODS

A descriptive cross-sectional study was conducted from April to November 2015. It included auxiliaries of private pharmacies in Abidjan. Data collection material was a structured an open pretested questionnaire. Data analysis was carried out using Package for Social Science (SPSS) software version 21.1. Chi square test was used to compare proportions for a significance threshold of 0.05 for the p value.

RESULTS

A total, 447 auxiliaries from 163 private pharmacies were interviewed. It was noted that the auxiliaries had a good knowledge of clinical signs of uncomplicated malaria (99.1%), biological examinations (54.6% for the thick film and 40.7% for rapid diagnostic tests (RDTs) and anti-malarial drugs (99.3% for artemether + lumefantrine, AL). The strategies of vector control (long-lasting insecticide-treated mosquito nets (LLITNs, Repellent ointments, cleaning gutters, elimination of larvae breeding site and intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) in pregnant women were also known by the auxiliaries, respectively 99.8% and 77.4%. However, the malaria pathogen (25.1%) and the NMCP recommendations (e.g. use of AL or AS + AQ as first-line treatment for uncomplicated malaria and IPTp-SP in pregnant women) were not well known by the auxiliaries (28.2% and 26.9% for uncomplicated and severe malaria). Concerning the practices of the auxiliaries, 91.1% offered anti-malarial drugs to patients without a prescription and 47.3% mentioned incorrect dosages. The combination artemether + lumefantrine was the most recommended (91.3%). The delivery of anti-malarial drugs was rarely accompanied by advice on malaria prevention, neither was it carried out on the result of an RDT.

CONCLUSION

The epidemiology and the NMCP recommendations for the diagnostic and therapeutic management of malaria, are not well known to auxiliaries, which may have implications for their practices. These results show the need to sensitize and train private pharmacy auxiliaries, and also to involve them in NMCP activities.

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

Identification of Confusing Medicine Proprietary Names: Toward Safe Medicine Use-A Cross-Sectional Study in Sri Lanka

BACKGROUND

Look-alike sound-alike (LASA) medications have similar pronunciation (phonetic) and/or manifestation (orthographic), which could create confusion among users and challenge the safe use of medicines. The availability of foreign products in local markets aggravates the situation. This study was designed to examine the registered medicine proprietary names in Sri Lanka to discern the presence of similar medicine names in the industry.

METHODS

A cross-sectional study was conducted on the registered drug proprietary names in Sri Lanka. Using the RAND and RANK functions in Microsoft® excel® 365, a random sample of 385 proprietary names was selected. Two evaluators independently evaluated each proprietary name in the sample against the other registered proprietary names following a stepwise text filtering method. After each filter, the resulting proprietary names were manually examined for identical, similar-looking, and similar-sounding proprietary names to the name under evaluation. The observations were matched, categorized, and collated into ten groups.

RESULTS

Among the 385 names evaluated, 138 (35.84%) proprietary names had no similarity to existing other registered proprietary names. The rest of the names (n = 247, 64.15%) were found to be either identical (n = 03 pairs), look-alike (n = 91 pairs), or sound-alike (n = 80 pairs) to the registered proprietary names.

CONCLUSION

The findings revealed the presence of equal and similar proprietary names in the system. A multifactorial strategy led by the National Medicine Regulatory Authority (NMRA) is recommended to minimize the confusing names entering the system. Primarily the NMRA's call for action should include adequate industry guidance with specific guidelines, a significant pre-submission assessment process, and denying approval of LASA proprietary names.

A Comparative Analysis of Public Hospital Pharmacy Systems in Norway and Pakistan: A Pilot Implementation of the American Society of Health-System Pharmacists’ (ASHP) Guidelines

The objective of the study was to analyze and compare public hospital pharmacy practices in Pakistan and Norway. In addition, the study intended to identify the challenges to improving the public hospital pharmacy system and to propose recommendations that could help reform the practice to enhance patient safety and compliance. A cross-sectional study was conducted to understand public hospital pharmacies’ organizational structure and determine their practices in Norway and Pakistan. The results of the research showed differences in 11 main areas of the pharmacy systems of the sampled hospitals. When compared to Norway, the study found that the public hospital pharmacy system in Pakistan could be improved in nine main areas. The results show that hospital pharmacies in Pakistan could benefit from the experience of similar international structures in relation to universal standards and practices.

Compliance of Private Primary Health Care Facilities Towards Requirements of Labelling of Dispensed Medicine in Sarawak

BACKGROUND

Compliance towards the requirements of labelling of dispensed medicine (LDM) among private primary health care facilities ensures appropriate use of medicines.

AIM

This study aimed to examine the rate of compliance towards the requirements of LDM among retail pharmacies (RPs) and private medical clinics (PMCs).

METHODS

A cross-sectional study was conducted from April 2019 to January 2020 across all inspected premises in Sarawak. Publics who attended RPs and PMCs and having medicines dispensed, have their medicine labels examined for compliance towards the requirements of LDM upon exiting the premises. Their verbal consents were obtained and the compliance score were recorded into self-developed data collection forms. Compliance rate was the percentage of requirements on the examined medicine labels that fulfil the requirements under Regulation 12 of Poisons Regulations 1952.

RESULTS

A total of 414 LDM were examined, with 135 from RPs and 279 from PMCs. The full compliance towards the requirements of LDM among RPs and PMCs were 23.7% and 41.6%, respectively. The median compliance score of PMCs (0.83) was significantly higher (P<0.001) than RPs (0.67). The requirements of LDM with the lowest compliance was name of medicine (53.1%), followed by name of patient (31.9%) and date of dispensing (25.6%).

CONCLUSION

The full compliance rate on the requirements of LDM among RPs and PMCs were low. More stringent enforcement and public education on their rights for fully compliant medicine labels could improve the compliance.

The extent of community pharmacists' involvement in detecting and resolving Drug Related Problems (DRPs) in prescriptions – A real time study from Sri Lanka

Background

Appropriate medication use is necessary to ensure patient safety. Drug Related Problems (DRPs) could result in patient harm.

Purpose

To assess the prevalence and types of DRPs in prescriptions, and the proportion of DRPs detected and resolved by community pharmacists during dispensation of prescriptions in a selected community pharmacy.

Methods

A prospective, cross-sectional study was conducted in a selected community pharmacy in Colombo, Sri Lanka, where one researcher reviewed for DRPs in systematically selected prescriptions (N = 400), and another directly observed the frequency of DRPs identified by community pharmacists in the same set of prescriptions. Actions taken by pharmacists on resolving DRPs were also documented. DRPs were classified according to a slightly modified version of Pharmaceutical Care Network Euro pe classification V8.01. Descriptive and comparative data analysis were performed using SPSS database V.21. P < 0.05 was considered as significant.

Results

Among 1986 medications, a total of 1211 DRPs were identified by researchers, of which only 441 DRPs were detected by community pharmacists who participated in the study (N = 24). DRPs identified by the researcher were related to medication selection (N = 15), medication form (N = 1), dose selection (N = 817), duration of treatment (N = 128), incomplete prescriptions (N = 128), and other (outdated prescriptions, missing unit of measurements, and ambiguous names of medications that could not be read by both community pharmacists and researcher) (N = 122) of which only one, one, 394, 13, five, and 27 were identified by pharmacists, respectively. Among 441 DRPs identified by pharmacists, 406 were resolved by them. Most DRPs were self-resolved by pharmacists themselves (367/406), while patients were also sent back to the prescriber (13/406), and some dispensation of medications to patients were refused (9/406).

Conclusion

Among the DRPs frequently observed in the sample of community prescriptions, the community pharmacists identified significantly fewer DRPs in relation to each type identified by the researcher, and pharmacists missed some, including incomplete prescriptions, that had potential to harm. Systematic and sustainable training of pharmacists on performing a preliminary prescription review and continuous education programs must be implemented to improve community pharmacist dispensing practices in this community.

Access to WHO Essential Medicines for Childhood Cancer Care in Trinidad and Tobago: A Health System Analysis of Barriers and Enablers

PURPOSE

Improving access to essential medicines is necessary to reduce global mortality resulting from childhood cancer. However, there is a lack of context-specific data in many low- to middle-income countries on the determinants of access to essential childhood cancer medicines. We conducted a mixed-methods case study of the barriers to and enablers of access to WHO essential medicines for childhood cancer care in Trinidad and Tobago, in response to domestic calls for policy attention and reform.

METHODS

We interviewed stakeholders (N = 9) across the pharmaceutical supply system using a novel analytic framework and qualitative interview guide. Interviews were recorded, transcribed, and analyzed with constant comparative methods to capture emergent themes. Quantitatively, we examined alignment of the national essential medicines list with the 2017 WHO Essential Medicines List for Children (EMLc). National buyer prices for EMLc cancer medicines were compared with median international prices, with calculation of median price ratios to assess procurement efficiency.

RESULTS

Principal barriers identified included a lack of data-driven procurement, low supplier incentive to engage in tenders, reactive rather than proactive processes in response to stockouts, and siloed information systems. Recurring themes of regionalization, standardization, and proactivity emerged as priorities for policy reform. Quantitative analysis of the national essential medicines list and median price ratios for procured medicines aligned with findings reported qualitatively.

CONCLUSION

Our study contributes to global efforts to improve childhood cancer care by identifying policy-relevant evidence on access to essential childhood cancer medicines and providing a model for future studies in other jurisdictions.

Are medications safely used by residents in elderly care homes? - A multi-centre observational study from Sri Lanka

BACKGROUND

Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services.

OBJECTIVE

To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka.

METHODOLOGY

This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications.

RESULTS

The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%).

CONCLUSION

Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.

Dispensing practices for anti-malarials in the La Nkwantanang-Madina municipality, Greater Accra, Ghana: a cross-sectional study

Background

Despite recent strides made towards reducing the emergence of artemisinin resistance, inappropriate dispensing practices for anti-malarials in both private and public sectors affect treatment outcomes negatively. In Ghana, private retail pharmacies are the most accessible health facilities for managing diseases of common occurrence. However, there is growing concern about the number of patients harmed by dispensing errors in the management of malaria in retail pharmacies. Although considerable work has been done in this area, several questions regarding dispensing practices remain unanswered. This study, therefore, sought to investigate the predictors of appropriate dispensing practices for anti-malarials in community pharmacies in the La Nkwantanang-Madina municipality of Greater Accra, Ghana.

Methods

A cross-sectional analytic study was conducted in sixty-one randomly selected community pharmacies in the La Nkwantanang-Madina. Data from 230 clients and 106 dispensers were analysed. It was checked for internal consistency and completeness then entered and analysed using STATA I/C version 14.0. Frequencies, Chi square tests, and logistic regression analyses were conducted, accounting for clustering.

Results and discussion

Of the 106 dispensers interviewed, 71.4% were medicine counter assistants. The mean age of dispensers was 30.4 years (SD 8.8). Over 88.0% of clients were advised to complete the full course of their anti-malarials. However, the 8-h loading dose principle for artemether-lumefantrine was not explained to 88.3% of the clients. More than half of the clients (52.2%) were given appropriate dispensing information on anti-malarial use. Most clients (66.1%), were dispensed anti-malarials without malaria tests. Dispensers with more than a 10-years experience were less likely to dispense artemisinin-based combinations appropriately relative to dispensers with less than 2 years experience (AOR = 0.04, 95% CI 0.002–0.802 p-value = 0.036) while pharmacy interns were about 19 times more likely (AOR = 18.5, 95% CI 1.40–245.6 p-value = 0.03) to dispense artemisinin-based combinations appropriately compared to pharmacists.

Conclusion

Dispensing practices for anti-malarials is unsatisfactory. There is a need to enforce existing legislation with educational programmes directed towards dispensers especially those with more than 10 years experience. Specific adherence to the World Health Organization Test, Treat and Track initiative should be encouraged to ensure effective use of anti-malarials.

The Need to Strengthen the Role of the Pharmacist in Sri Lanka: Perspectives

The role of the pharmacist in healthcare has evolved greatly over the last half-century, from dispensing to providing direct patient-oriented activities not associated with dispensing. However, pharmacist-led healthcare services in Sri Lanka must undergo reform to fully take advantage of their expertise and training in medicine management and related outcomes in Sri Lankan patients. As befits a profession's role development and value, professional and educational standards for pharmacists need ongoing development and growth. Currently, university curricula and continuing professional education in Sri Lanka require further development and optimisation to provide the theoretical and practical knowledge and skills regarding quality use of medicines and patient-oriented care. Furthermore, pharmacists' roles in Sri Lankan hospital and community pharmacist settings need to be recognised and should include the pharmacist as an integral part of the multidisciplinary healthcare team in Sri Lanka. Studies from developed countries and some developing countries have demonstrated that expanded pharmacists' roles have had a significant positive cost-effective impact on the population's health. Therefore, the availability of qualified Sri Lankan pharmacists trained to deliver expanded professional services accompanied by greater pharmacist integration into healthcare delivery is crucially important to ensure quality use of medicines within the Sri Lankan healthcare system and optimise the medication-related needs of Sri Lankans.

Assessment of primary labeling of medicines manufactured by Nepalese pharmaceutical industries

Background

Appropriate labeling of marketed medicines is necessary to fulfill the regulatory provisions and ensure patient medication safety. This study aimed to assess the primary labeling of medicines manufactured and marketed by Nepalese pharmaceutical industries.

Methods

We assessed the primary labeling of all medicines available at the pharmacy of Chitwan Medical College Teaching Hospital (CMCTH), Chitwan, Nepal, between November 2017 to December 2017. Medicines were assessed as required by Drug Standard Regulation, 2043 (1986 AD) of Nepal. Appropriate classification of all the medicines and content of over-the-counter (OTC) medicines (where certain information should be in Nepali language) was also assessed. Descriptive statistics was performed.

Results

Seven hundred fifty-nine medicines manufactured by 37 Nepalese pharmaceutical industries were assessed. While all pharmaceutical products had the name of the drug (brand), only76.8% of them stated drug quantity. Almost all products were found to declare category of the drug, with only a few (4.1%) mentioning the sub-category. The system of medicine was stated in 9.9% of the products. Active ingredients and their quantity, manufacturer’s information, serial number for the production of drug and the date of production, storing methods, and information on the quantity used were mentioned in almost all the products. Similarly, all the products had batch number and the date of expiry. But, 11% of the products lacked the name of pharmacopoeia to which the drug belongs and all the products lacked the serial number for establishment of pharmaceutical industry. Similarly, 5.3% of the products did not list their price, and 2.4% of prescription medicines lacked caution labeling. Unfortunately, the majority of the products (84.4%) did not provide the directions of use. Appropriate drug classification was found in 89.6% of products. None of the over-the-counter medicines totally adhered to the requirements for writing certain information in Nepali language.

Conclusions

Majority of the products did not meet the regulatory standards of primary labeling of Nepalese pharmaceutical products. This study highlights the necessities for improvement from all stakeholders.

Patients' ability to read and understand dosing instructions of their own medicines - a cross sectional study in a hospital and community pharmacy setting

BACKGROUND

Poor communication of medicines information to patients may cause medication errors. We assessed the completeness and readability of dosing instructions provided by pharmacists on dispensing labels and knowledge among patients on dosing instructions of their medicines.

METHODS

A cross sectional study was conducted in a selected teaching hospital, and a community pharmacy, among 800 patients selected through a systematic sampling method, during a period of 2 months. Completeness of dosing instructions were assessed against a checklist. Patients were asked to read dosing instructions to assess readability. Patient knowledge on dosing instructions were determined through a questionnaire. Completeness, readability and knowledge were scored out of 10 for each dispensing label.

RESULTS

A total of 1200 and 1372 dispensing labels were assessed in the hospital and community settings respectively. The median score out of 10, for completeness, readability and patient knowledge of dosing instructions were 6.7, 8.3 and 7.5 respectively in the hospital, and 7.5, 8.0 and 7.5 respectively in the community. Only a few dispensing labels had the route of administration (hospital, 0.5%; community, 0.8%) and the duration of treatment written (hospital, 0.25%; community, 0.65%) on them. Name (hospital, 48%; community, 27.3%) and strength (hospital, 40.2%; community, 36.6%) of medicines on dispensing labels were frequently misread. In both settings, readability scores significantly differed with education level (P < 0.001).

CONCLUSIONS

Some important dosing instructions were missing in dispensing labels. Readability of dosing instructions by patients was also not 100% and differed by their education level. Pharmacists did not adhere to a standard procedure in providing dosing instructions leading to communication gaps with patients. Hence we recommend the development of a standard procedure to provide complete, clear and simple dosing instructions to patients, and continuous training for pharmacists on proper communication of dosing instructions to patients.