Open Access Te Herenga Waka-Victoria University of Wellington
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Investigating the Role of Labelling and Packaging on Medication Error

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posted on 2021-11-16, 01:15 authored by Bailey, Carrie

Medication administration error contributes to deaths and injury in hospitals, especially in the area of anaesthesia. Labelling and packaging contribute to medication error. The current study examined the role of labelling and packaging in medication error and compared medically trained and medically naive participants.  Using eye-tracking equipment, Study 1A investigated the distribution of fixations across 32 pre-existing medication labels and packages. Both groups of participants fixated less on the dose and top of medications than on the name and ‘other’ features. Both medical experience and packaging type influenced on which label areas participants fixated. Medical participants fixated on dose more than control participants; there were no other differences between groups.  In Study 1B participants viewed a target medication, they were then asked whether it was present in an array. The target was present in 50% of arrays. Distractors varied in similarity to the target. Signal detection theory analysis of discriminability through d’ revealed that medical participants were significantly better than control participants at discriminating whether or not the target was in the array. Bias analyses through C revealed that there was no difference between the biases of the two groups. Both groups of participants adopted a liberal criterion which increased the occurrence of false alarms. Across all trials, participants were most likely to select a distractor that differed only in the dose of the medication.  Divided attention can increase medication error rates, therefore Study 1C utilised the same procedure as Study 1B and added a divided attention task. During the divided attention task participants saw a string of either five or seven letters and were later asked to recall one of the letters. Both groups of participants recalled fewer letters in the seven-letter compared to five-letter condition. There was no difference in the overall performance of the two groups on the divided attention task. Both groups showed a significant reduction in discriminability under the seven- compared to five-letter divided attention condition. Medical participants had significantly higher discriminability indices than control participants. Both groups of participants adopted a liberal criterion, however control participants were more biased than medical professionals. Control participants displayed an increase in bias in the seven-letter, compared to five-letter condition; the bias of medical participants was not influenced by the divided attention task. As in Study 1B, participants were most likely to select a distractor that differed only in the dose of the medication.


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Date of Award



Te Herenga Waka—Victoria University of Wellington

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Author Retains Copyright

Degree Discipline


Degree Grantor

Te Herenga Waka—Victoria University of Wellington

Degree Level


Degree Name

Master of Science

ANZSRC Type Of Activity code


Victoria University of Wellington Item Type

Awarded Research Masters Thesis



Alternative Title

Medication Error and Labelling

Victoria University of Wellington School

School of Psychology


Macaskill, Anne; Robinson, Brian