J. Pac .Sci. Tech.

Vol.28No.6（2019）

Original Paper～～～～～～～～～～～～～～～～～～～～～～～～～～～～

Identification Study of Information on Short-Side
Surface of Medical Drug Individual Package Case
Teruyuki YAMAMOTO*, **, Kenichi NEGISHI***, Ayako FUKUI ***, Kohei MIYASO****,
Takao AOYAMA***, and Naoki KAMIMURA***The purpose of this research was to clarify the identification of the information on the short-side
surface of individual package cases through an experiment from the viewpoint of the prevention of
mistakes in picking up medical drugs. Subjects were shown sample sheets depicting the front designs ofindividual package cases, and they were asked to identify the specified medical drugs from the sample
sheets in which the designs on the short-side surface of individual package cases were randomly arranged,
which was prepared by imaging the drawers of a dispensing table, and the time required (in seconds) for
identifying the specified medical drugs were compared. The times required (in seconds) weresignificantly shorter in both the pharmacist group and student group when the coloring of the short-side
surface was the same as that of the front-side surface. Compared with the cases where the coloring of theshort-side surface was not the same as that of front-side surface, the gaze on heat map was more stable.
These results suggest that information such as coloring and design on the short-side surface of anindividual package case greatly affects the identification of the medical drugs.
Keywords：medical drug individual package case, short-side surface, design, coloring

1. Introduction
Recently, the number of medical drugs that pharmacies keep in stock is becoming greater 1, 2). Oneof the reasons is considered to be the prevalence of branded generic drugs. According to the results of thespecial investigation involved in the result verification of the 2016 Revision of the Medical Payment
System, the increasing rate of stockpiled items of branded generic drugs was 11.0% (from June 2016 toJune 2017) 2). According to the 2016 Revision of Dispensing fee, one of the calculation requirements of“Additional Medical Fees for Standard Dispensing” is to “stockpile more than 1,200 items of medical
drugs involved in insurance dispensing 3). The “Additional Medical fee for Community Support System”
was newly established in place of the “Additional Medical Fees for Standard Dispending” which wasabolished by the 2018 Revised Dispensing fee. It made family pharmacists fulfill their functions andevaluated pharmacies contributing to community-based health care under a community-based integrated
care system; there is a similar calculation required for this additional fee 4, 5). It is considered that these*

Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University; 1-1-1 Daigakudori, Sanyo-Onoda 756-0884, Japan
Jinjo Pharmacy; 3200-5 Kume, Shunan 745-0801, Japan***
Faculty of Pharmaceutical Sciences, Tokyo University of Science; 2641 Yamazaki, Noda 278-8510, Japan****
Toyama Sugaki Co.,Ltd.; 23-1,Tsukahara ,Toyama 939-8585,Japan**

Corresponding author: Teruyuki Yamamoto. Tel:0834-26-2490, Fax:0834-26-2484, E-mail: yoyogi_p_yamamoto@ybb.ne.jp－ 399 －

Identification Study of Information on Short-Side Surface of Medical Drug Individual Package Case

things together with the prevalence of branded generic drugs became the causes of increasing thestockpile of items in insurance pharmacies. As a result, many pharmacies store medical drugs not only on
the shelves above the dispensing table but also have to store them in the drawers of dispensing tables. It isconsidered that medical drugs stored on the shelves above the dispensing table are in the condition of PTP
sheets being taken out from individual package cases or in the condition they are still in individual
package cases. However, in many cases, the medical drugs with PTP sheet still in individual package
cases are stored in the drawers. Therefore, pharmacists pick up medical drugs in drawers, in particular, byidentifying only the design on the short-side surface of individual package cases. Therefore, in thisresearch, the identification of the information of the short-side surface of individual package cases wasclarified from the viewpoint of the prevention of mistakes in picking up medical drugs. Comparative
experiments were conducted targeting pharmacy students who were the least accustomed to pharmacy
services among the qualified students and professional pharmacists in its engagements.

2. Methods
2.1 Subjects
Students Group:
Thirteen students from six grades of Tokyo University of Science, Faculty of Pharmaceutical Science
Pharmacists Group:
Twenty-one pharmacists from Jinjo Pharmacy and its affiliate pharmacies

2.2 Device used
A device for recording eye movement (hereinafter referred to as “eye tracker”):
Tobii Pro Glasses 2® (Tobii Technology)

2.3 Identification Experiment2.3.1 Comparison of the times required (in seconds) for finding medical drugs by
the presence or absence of coloring
The subjects were shown a sheet depicting the front designs of individual package cases (Fig. 1) andthey were asked to find specified medical drugs from two kinds of sample sheets where the designs on the
short-side surface of individual package cases were randomly arranged (sample sheet A assuming designs
different by each medical drug (Fig. 5), and sample sheet B assuming uniform design of a pharmaceuticalcompany (Fig. 6)), and the times required (in seconds) for finding medical drugs were compared.
Sample sheets were created as follows: As for pharmaceutical agents which begin with “ア”, “a”, 63
items were selected for usage frequency in pharmacies in descending order. On a sheet which represented
storage drawers, 1 – 63 location numbers were allocated. The location numbers and the item names of 63
pharmaceutical agents were input to Microsoft Excel and random numbers were generated for agent cells
employing the RANDBTWEEN function. Randomized numbers were applied from “1” in ascendingorder and then, duplicated numbers were randomized using random numbers which were not overlapped.
In all experiments, the same sample sheet was used for all participants.

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In creating package designs of a short-side surface, we decided the size of the short-side surface as
overall dimensions referring to a PTP package of 100 standard tablets, in consultation with TOYAMASUGAKI Co., Ltd., a manufacture of packaging. Basic designs were employed, where font type, positionand size were selected in accordance with general-use packages. Layout of drug names and specifications
were chosen with consideration of questionnaire results in our previous research for pharmacists.
Experiment time was measured from a start signal (showing a sample sheet and letting subjects know
by voice) until an end signal (subjects told the assigned drug name by voice and pointed to the drug.) The
recorded videos were observed by multiple researchers and then, time durations (in seconds) wererecorded.
Before the experiment, individuals were informed that “the design on the front surface and that on the
short-side surface are not always the same” and two experiments were conducted such as I) looking forthe cases with the same coloring on the short-side surface as on the front surface and II) looking for thecases without the same coloring on the short-side surface as on the front side surface.

Fig. 1 Examples of the designs on the front surface of individual package cases
shown to subjects

2.3.2 Gaze Analyzing Investigation
The subjects were fitted with an eye tracker, and their gaze trajectories during the experiment wererecorded, and at the same time, their ranges of eye movement were analyzed from the heatmap visualized
by changing the gaze retention times to the colors from green to yellow to red (short to medium to longtime).

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Identification Study of Information on Short-Side Surface of Medical Drug Individual Package Case

2.4 Hearing Investigation
After the identification experiment, all subjects were questioned about the order of confirmation of four
elements of the designs of individual package cases of sample sheets, such as name of product,
specification-small, specification-large and the color band in the lower part. Furthermore, pharmacists
were additionally questioned whether they are dispensing drugs while imaging the front surface ofindividual package cases.

2.5 Statistical Analysis
The times required (in seconds) were statistically analyzed by a Student’s t-test with a significant
difference of p<0.05. Excel 2016 for Mac was used as analysis software.

3. Results
3.1 Identification Experiment3.1.1 Comparison of the times required (in seconds) for finding medical drugs by
the presence or absence of coloring

Fig. 2 Comparison of times required (in seconds) for finding “with coloring” and “without coloring”
by the pharmacist group
The times required (in seconds) for finding “with coloring” and “without coloring” of sample sheets
A and B by the pharmacist group (n = 21) were measured and compared after “average ±standard deviation” being calculated. They were analyzed by Student’s t-test with a significant
difference of P < 0.05 and shown with ＊.

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Fig. 3 Comparison of times required (in seconds) for finding “with coloring” and “without coloring”
by the student group
The times required (in seconds) for finding “with coloring” and “without coloring” of sample sheets
A and B by the student group (n = 13) were measured and compared after “average ± standard
deviation” being calculated. They were analyzed by Student’s t-test with a significant differenceof P < 0.05 and shown with ＊.
Regarding medical dugs with the same coloring on the short-side surface as on the front surface ofindividual package cases (hereafter referred as “with coloring”) and those without the same coloring on
the short-side surface as on front surface of individual package cases (hereafter referred as “without
coloring”), the times required for finding medical drugs by the pharmacist group are shown in Fig. 2, andthose by the student group are shown in Fig. 3; and the times required for finding medical drugs “withcoloring” shown in sample sheets A and B by both groups are shown in Fig. 4. The times required by thepharmacist group (average ± standard deviation) were 4.3 ± 2.8 seconds in the case of sample sheet A“with coloring,” 10.5 ± 6.1 seconds in the case “without coloring,” 7.6 ± 4.4 seconds in the case ofsample sheet B “with coloring” and 11.0 ± 6.3 seconds “without coloring.” The times required by thestudent group (average ± standard deviation) were 4.5 ± 2.4 seconds in the case of sample sheet A “withcoloring,” 15.2 ± 9.3 seconds “without coloring,” 7.2 ± 3.3 seconds in the case of sample sheet B “withcolor” and 10.8 ± 4.5 seconds “without coloring.” In both sample sheets A and B, the times required weresignificantly shorter when it was “with coloring.” Furthermore, as the comparison between sample sheets
A and B, in the case of sample sheet A, when it was “with coloring,” the times required were significantly
shorter in both the pharmacist group and the student group.

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Identification Study of Information on Short-Side Surface of Medical Drug Individual Package Case

Fig. 4 Comparison of times required (in seconds) for finding “with coloring” shown in sample
sheets A and B by the pharmacist group and the student group
From the required times (in seconds) (average ± standard deviation) for finding “with coloring” by
the pharmacist group (n = 21) and the student group (n = 13), sample sheets A and B werecompared by each group, and the results were shown. They were analyzed by Student’s t-test
with a significant difference of P < 0.05 and shown with ＊.

3.1.2 Gaze Analyzing Investigation
The heatmaps of the experiment using sample sheet A are shown in Fig. 5 and those of the experimentusing sample sheet B are shown in Fig. 6. (Heatmaps of 17 subjects of the pharmacists were analyzable.)
When searching for “with coloring,” the gaze on the heatmap was more stable than when searching for“without coloring” in both sample sheets A and B.

3.2 Hearing Investigation
The orders of the confirmation of the design of a product are from band color to product name to
specification (large) by 11 subjects; from band color to specification (large) to product name by eightsubjects; from product name to specification (large) by seven subjects; from band color to product nameto specification (small) by five subjects and from product name to specification (small) by three subjects.
Twenty-four subjects (70.6%) identified the medical drug from the band color on the lower part ofindividual package cases; 15 pharmacists (71.4%) and nine students (69.2%). Twenty-six subjects(76.5%) confirmed with the specification (large), which is strongly emphasized with coloring (Fig. 7); 17－ 404 －

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pharmacists (81.0%) and nine students (69.2%). To the question asked only to pharmacists about whether
they are dispensing medical drugs while imaging the front surface of individual package cases, elevenpharmacists (52.4%) answered that they are doing so while imagining it at least a little.

Fig. 5 Heatmap generated from eye tracker on sample sheet A
This is the figure of the heatmap showing gaze retention times of “with coloring” (middle) and“without coloring” (right) being superimposed on sample sheet A (left). The colors shown on theheatmap show longer gazing times in an ascending order from green to yellow to red.

Fig. 6 Heatmap generated from eye tracker on sample sheet B
This is the figure of the heatmap showing gaze retention times of “with coloring” (middle) and“without coloring” (right) being superimposed on sample sheet B (left). The colors shown on theheatmap show longer gazing times in ascending order from green to yellow to red.

Fig. 7 Examples of medical drugs with the same coloring on the short-side surface as on thefront surface of individual package cases.

4. Discussion
When finding medical drugs with the same coloring on the short-side surface as on the front surface ofindividual package cases, the times required (in seconds) were significantly shorter than the cases without－ 405 －

Identification Study of Information on Short-Side Surface of Medical Drug Individual Package Casethe same coloring on the short-side surface as on the front surface and the gaze on the heatmap was morestable, which suggests that information such as coloring greatly affects identification on the short-side ofindividual package case. Even though it was informed to the subjects before the experiment that thedesign on the front surface and that on the short-side surface are not always the same, more than half ofthe subjects (70.6%) identified medical drugs by the colored part of the design (band color). At thehearing investigation after the experiment, to the questions asked to pharmacists whether they are
imagining the front surface of individual package cases while dispensing medical drugs, even though
there were differences in frequency in the imaging, more than half of them answered “yes.” Therefore,
when the coloring and layout on the short-side surface are different from those on the front surface,
pharmacists may be bewildered when dispensing medical drugs and it may lead to a mistake in picking
them up. Therefore, in order to prevent mistakes in picking up medical drugs, the coloring on the
short-side surface should be the same as that on the front surface of individual package cases.
This research was conducted targeting a student group and a pharmacist group, and some differenceswere observed between the two groups. The student group consisted of students in their sixth year of apharmaceutical department, who acquired basic pharmaceutical knowledge and five-months of experienceat pharmacies and hospitals as a training course. Thus, these students were supposed to have skills
relatively comparable to newly qualified pharmacists. Comparing both groups, these experiments cansuggest points of attention to produce a training course for pharmacy students and supervise fresh
pharmacists. As a result, when finding medical drugs without the same coloring on the short-side surfaceof the sample sheet A where a different design is assumed by each medical drug, there was a difference of
4.7 seconds between the average times required by the pharmacist group and the student group; therefore,
it is considered that the student group was more dependent upon coloring when finding medical drugs
more than the pharmacist group was. However, in the hearing investigation on the order of confirmationof products after the experiment, the subjects who found medical drugs by color (color band) were nine
students out of 13 (69.2%) and 15 pharmacists out of 21 (71.4%); there was no difference between thestudent group and the pharmacist group. It can be considered, because the pharmacist group did notdepend on coloring only even when they confirmed medical drugs by coloring, they did not require as
much time as the students did even when there was not the same coloring on short-side surface. Fromthese facts, it was presumed that the presence or absence of coloring on the short-side surface ofindividual package cases is a very important factor for students and pharmacists without enoughexperience when dispensing medical drugs. Furthermore, as the comparison of sample sheets A and B,
when finding medical drugs with the same coloring on the short-side surface as on the front face ofindividual package cases, in the case of sample A, the times required (in seconds) were significantly
shorter for both the student group and the pharmacist group, so even though several pharmaceuticalcompanies employ a company uniform design, it is also important to consider the design and coloring ofeach product unit.
Furthermore, from the hearing investigation after the experiment, it was revealed that 76.5% of thesubjects confirmed medical drugs by the part of specification greatly emphasized by coloring, whichmeans the part of design (coloring in the shape of belt at the under part of individual package case in thisexperiment) is highly paid attention to, so that if the specification is described there, it can prevent
mistakes in specification. However, as the space of the short-side surface is smaller than that of the front－ 406 －

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Vol.28No.6（2019）surface of individual package cases, the amount of information that can be described in this space also
becomes smaller. Recently, due to the prevalence of branded generic drugs, long medical drug names
often can be seen, and therefore, the blank space becomes narrower and the space for a design is limited.
From this experiment, it was revealed that coloring is an important identification element. Therefore, it isnecessary to discuss how to describe a design with colors in the limited space on the short-side surface ofindividual package cases.
This research is for the comparison of presence and absence of colors on the short-side surface ofindividual package cases; however, as other factors, there are color combinations, shape of designs,
character fonts and pictograms. Even though it is for the purpose of the prevention of mistakes while
picking up medical drugs, it is clear that there are many complicated factors such as requirements forkeeping the consistency of the medical drugs, the clarity of expression of the specification that is
important information, other miscellaneous standards and discrimination from other medical drugs 6). It isalso required to discuss what sort of design can improve medical drug identification, not centering on
colors only, but also the size and font of characters in the future.
Finally, in this research, the ranges of a subjects’ eye moving was visually confirmed via heatmap;
however, further research will also require comparing them by quantifying the ranges of eye movementfrom the retention time and arrival frequencies of gaze in each area. We will continue experimental
research for developing package designs and co-producing packages with a manufacturing company ofpharmaceutical packaging. We hope that highly distinguishable designs on improved package boxes willplay a key role in preventing picking errors from pharmacists.

References
1) Ministry of Health, Labour and Welfare, “Special investigation for verifying revision of medical fee(in 2008), Usage survey of generic medicines,”
https://www.mhlw.go.jp/shingi/2009/05/dl/s0520-4d.pdf (accessed 31 March, 2019).
2) Ministry of Health, Labour and Welfare, “Special investigation for verifying revision of medical fee(in 2016), Effects of the plan to enhance usage of generic medicines and its implementation report,”
https://www.mhlw.go.jp/file/05-Shingikai-12404000-Hokenkyoku-Iryouka/0000184209.pdf(accessed 31 March, 2019).
3) Kawakami Y., “Interpretation of the list of dispensing fee points,” ed. by Research Institute for Social
Insurance, Tokyo, pp. 31. (2016).
4) Suzuki S., “Interpretation of the list of dispensing fee points” ed. by Research Institute for Social
Insurance, Tokyo, pp. 34-36. (2018).
5) Japan Pharmaceutical Association, “Revised documents for dispensing fee,” ed. by Research Institutefor Social Insurance, Tokyo, pp. 12-15. (2018).
6) Komatsubara A., “Ergonomic study of medication packages with multiple units to prevent
mis-picking human error,” PHARM. TECH. JAPAN, 25, 49-56. (2009).
（Received 19August 2019）（Accepted 16September 2019）－ 407 －

Identification Study of Information on Short-Side Surface of Medical Drug Individual Package Case

医薬品個装ケース短側面情報の識別研究山本 晃之、根岸 健一、福井 絢子、宮宗 耕平、青山 隆夫、上村 直樹
本研究は薬剤師の医薬品取り間違え事故防止の観点から、個装ケース短側面情報の識別について実験を通して明らかにすることを目的とした。被験者に個装ケース正面のデザインが記載されたシートを見せ、調剤台の引き出しをイメージして作成した個装ケース短側面のデザインがランダムに並べられたサンプルシートの中から、指定した医薬品を探し出すまでの所要秒数を比較した。所要秒数は、薬剤師群・学生群ともに全ての場合で、個装ケース正面と同等の色が短側面にもある医薬品の方が有意に短かった。また、短側面に同等の色がない医薬品を探す場合と比較して、ヒートマップ上の視線のばらつきが少なかった。これらの結果から、個装ケース短側面での識別には色などの情報が大きく影響を与えていることが示唆された。
キーワード : 医薬品個装ケース、短側面、デザイン、色－ 408 －