Even if drugs are accurately dispensed, it is difficult to ensure their safety in the absence of an error-free medication system when or after drugs are given to patients. In particular, most powders are white and are impossible to distinguish based on appearance after thay are placed in powder packages. In this study, we newly developed a system in which prescription order information is bar-coded on drug envelopes, and read when powder is folded, facilitating efficient and accurate printing of the patient's name and drug name on powder packages. Seventy-one (86%) of 83 nurses surveyed indicated that the system was useful for resolving high-risk problems they had experienced: “when powder was taken from the envelope, the contents were unknown”, and “the powder was administered to another patient.”
