It is often difficult for nurses to determine the content of powders that consist of several different medicines and sometimes medicines have been given to patients in error. To reduce this risk, we introduced a powder packaging machine with a printing system that produces packages with the patient's name and dosage information on them. We evaluated the introduction of the packaging machine through a questionnaire survey of nurses in general wards and parents of pediatric patients. It was found that 30% of nurses and 20% of parents had experienced medication errors due to absence of labeling on powder packages before introduction of the packaging machine and about 30% of the nurses and parents felt that the detailed labels printed by the packaging machine would prevent medication errors. The questionnaire included a section on possible invasion of privacy in the outpatient setting through the appearance of names on medicine packages and from the responses, we felt that the use of labels bearing patient names should be examined carefully to prevent this. In conclusion, we feel that the introduction of a powder packaging machine with a printing system has been beneficial to risk management and that additional improvements should be made to further reduce the risk of medication errors.
