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Identifying Facilitators and Barriers for Patient Safety in a Medicine Label Design System Using Patient Simulation and Interviews

Dieckmann, Peter PhD; Clemmensen, Marianne Hald PhD; Sørensen, Trine Kart PhD; Kunstek, Pina RN; Hellebek, Annemarie PhD

doi: 10.1097/PTS.0000000000000109
Original Articles

Objectives Medicine label design plays an important role in improving patient safety. This study aimed at identifying facilitators and barriers in a medicine label system to prevent medication errors in clinical use by health care professionals.

Methods The study design is qualitative and exploratory, with a convenience sample of 10 nurses and 10 physicians from different acute care specialties working in hospitals in the Capital Region of Denmark. In 2 patient simulation scenarios and a sorting task, the participants selected the medicines from a range of ampules, vials, and infusion bags. After each scenario and in the end of the study, the participants were interviewed. Notes were validated with the participants, and content was analyzed.

Results The label design benefited from the standardized construction of the labels, the clear layout and font, and some warning signs. The complexity of the system and some inconsistencies (different meaning of colors) posed challenges, when considered with the actual application context, in which there is little time to get familiar with the design features.

Conclusions For optimizing medicine labels and obtaining the full benefit of label design features on patient safety, it is necessary to consider the context in which they are used.

From the *Danish Institute for Medical Simulation (DIMS), Center for Human Resources, Capital Region of Denmark, Herlev Hospital, Herlev Denmark; †The Danish Research Unit for Hospital Pharmacy, Amgros, Copenhagen, Denmark; ‡Regional Office for Patient Safety, Capital Region of Denmark; §Department of Diagnostic Services, University of Copenhagen, Copenhagen, Denmark; and ∥Danish Society for Patient Safety, Copenhagen, Denmark.

Correspondence: Peter Dieckmann, PhD, Danish Institute for Medical Simulation (DIMS), Center for Human Resources, Capital Region of Denmark, Herlev Hospital, 25th floor, Herlev Ringvej 75, 2730 Herlev Denmark (e-mail:

The authors disclose no conflict of interest.

This work should be attributed to the Danish Institute for Medical Simulation (DIMS).

The Danish Institute for Medical Simulation (DIMS) has a collaboration agreement with Laerdal, a manufacturer of patient simulation.

Amgros is a noncommercial company and has no economic interest in the present study.

Supported by a grant from the Tryg Foundation (TrygFonden) in Denmark (

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