Minutes of meeting no. 3 of the Network for the Prevention of Medication Errors held on 2 April 2009

03 June 2009

The meeting was held on Thursday 2 April 2009 at the Danish Medicines Agency.



  1. Welcome by Anne-Marie Vangsted
  2. Presentations from the Danish Medicines Agency
  3. Review of the Heparin case
  4. Medicinal product labelling
  5. Status on the High-Risk Medicines Working Group
  6. Presentation by Christianna Marinakis, Danish Drug Information
  7. Warning symbols at www.medicin.dk
  8. Presentation by Johanne Åkermann Nielsen, representative from the Danish Association of the Pharmaceutical Industry
  9. Identification of medicinal products and limitations in production
  10. Evaluation of the network, presentation by the Danish Medicines Agency
  11. Next meetingWednesday, 18 November 2009 at 13:00-16:00
  12. Any other business


Re item 1 Welcome
Anne-Marie Vangsted welcomed members to the meeting.

Re item 2a Review of the Heparin case
Anne-Marie Vangsted gave an account of the Heparin case from 2008, where counterfeit raw heparin had been sold under the pretence of being raw heparin. The case implied regulatory changes and meant that the monographs of the American and European pharmacopeias had to be adjusted. See the attached presentation (in Danish only).

Re item 2b Medicinal product labelling
Eva Sandberg gave a presentation of the labelling of biological medicinal products, which also included a specific case about the MMR vaccine. See the attached presentation (in Danish only).
At the end of the presentation, Eva Sandberg gave an example of two packages from the same manufacturer which will be evaluated to find out whether they are at risk of being mixed-up. On this basis, the participants proposed to use an independent body to review or approve packaging material, which is the practice applied in the USA and Sweden.

Re item 3 Status of the High-Risk Medicines Working Group
Linda Thomsen and Christianna Marinakis from the network's High-Risk Medicines Working Group briefed the attendants that the work of preparing definitions and a list of high-risk medicines is progressing as planned. The definition of high-risk medicines would be based on:
1. The medicinal product's pharmacological properties (e.g. narrow therapeutic index)
2. Compliance (instances where patients have misunderstood the dosage)
3. Errors in medication process (instances of incorrect handling by healthcare staff).

Re item 4 Warning symbols at www.medicin.dk
Christianna Marinakis gave a presentation of the Danish Drug Information's warning symbols tagged to estimated high-risk medicines. The warning symbols are displayed under the individual medicinal product at www.medicin.dk. See the attached presentation (in Danish only).

Re item 5 Identification of medicinal products and limitations in production
Johanne Åkermann Nielsen presented the industry's proposal on how the future bar codes could look like and their implicit challenges. The aim is to achieve a harmonised bar code (2D-3D) throughout the EU. This may presumably prevent administrative errors in the handling of medicinal products. See the attached presentation (in Danish only).
The presentation opened a discussion on whether dose dispensing has lead to a decrease in medication errors. It was revealed that dose dispensing had actually made the medication routine more difficult for the elderly because the bags are difficult to open. Nurses working in the home nursing services experience that medicine management has become more difficult because the patient's medicine is located in different places, either in the form of dose dispensed medicine or in the form of ordinary medicine. Furthermore, the barcode reading of dose dispensed medicinal products is not working properly at hospitals. So far only one department at the Århus University Hospital and the Department of Neonatology at the Copenhagen University Hospital have introduced it. Comments were also made about the problem that doctors often prescribe another product than the generic version available in the medicine room.
The network awaits the results from the evaluation of the new design for SAD products, which involves barcodes on all medicinal products.

Re item 6 Evaluation of the network
Lone Stengelshøj Olsen invited the participants to evaluate the network, see the attached presentation (in Danish only).
It was widely agreed to maintain the network meetings even though some topics might overlap with the topics discussed at the "Safe medication" meetings held by the Danish Society for Patient Safety. It is easier to maintain dialogue in a smaller forum like the network which joins representatives from the authorities, industry and healthcare professionals. The industry benefits considerably from the meetings and genuinely wants to contribute further if necessary.
Themes proposed for future meetings:
- Electronic medicine card
- Generic substitution from the University of Southern Denmark
- Dose dispensing

Re item 7 Next meeting
Next meeting Wednesday, 18 November 2009 at 13:00-16:00

Re item 8 Any other business


Association of Danish Pharmacies: Linda Aagård Thomsen
Danish Drug Information: Christianna Marinakis
Association of Hospital Pharmacies in Denmark: Asta Haahr Nielsen, Lillian Brøndgaard Nielsen, Lene Stenbek
Danish Nurses’ Organization: Susanne Richter
Institute for Rational Pharmacotherapy: Marianne Møller
Danish Generic Medicines Industry Association: Lena Storm
Danish Association of the Pharmaceutical Industry: Johanna Åkerman Nielsen, Elisabeth Oladottir, Helen Shennan, Randi Bordoy, Marie Lund, Tine Kock Thorslund
Danish Medicines Agency: Anne Marie Vangsted, Marie Melskens, Eva Sandberg, Lene Havsteen, Lone
Stengelshøj Olsen, Sussi Mie Betak
PharmaDanmark: Helle Byg Armandi

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