Japanese
JournalVol.8,
No.1,
1-12(2020)
Japanese
JournalofofCommunity
Community Pharmacy
Pharmacy Vol.8,
No.1,
1-12
(2020)《 Original Article 》

The degrees of influences on identification via informationon the short-sides of a pharmaceutical packaging box
Teruyuki Yamamoto1,2＊, Kenichi Negishi3, Yasunari Mano3, Mio Aoki3,
Kohei Miyaso4, Naoki Kamimura3 and Takao Aoyama3
The purpose of this study, performing experiments and surveys, was to clarify the
influences on identification by short-side information of rectangular pharmaceuticalpackaging boxes, from the viewpoint of preventing pharmacists from dispensing errors suchas mixing up medications. In experiments, research participants were shown sample sheets
where designs were placed on the short-side surface of pharmaceutical packaging boxes.
Participants were assigned to identify designated pharmaceutical products within a given
time. In questionnaire surveys, they were queried regarding four types of “designs on the
short sides of rectangular packages” and six types of “designs for specifications”. The results
confirmed that for the distinctiveness of “short side designs”, the design type with different
design patterns based on each product and different colors based on each specification was
effective for identification. Furthermore, this survey clarified that a “specification design”
with distinctiveness for identification was the design type where each specification was
assigned different colors and other specifications were inscribed. It was suggested that colorrelated distinction for short-side designs was effective for identifying the same products. For
specification designs, however, a design which enabled pharmacists to perceive which
products had multiple strength types in the specifications was necessary to prevent
dispensing errors of picking the wrong dose specifications.
Key words; pharmaceutical packaging box, short side, design, color, multiple specifications
Received February 21, 2020; Accepted April 4, 2020

1． Introduction

health insurance pharmacies have increased in
number, along with promoted use of generic

Currently, pharmaceutical products stored inpharmaceutical products and due to changes of

1 Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University
3 Faculty of Pharmaceutical Sciences, Tokyo University of Science

2 Jinjo Pharmacy,

4 Toyama Sugaki Co.,Ltd.

*Corresponding author: Teruyuki Yamamoto, Jinjo Pharmacy, 3200-5 Kume, Shunan-shi, Yamaguchi 745-0801, Japan
Phone +81-834-26-2490
Fax +81-834-26-2484
E-mail: yoyogi_p_yamamoto@ybb.ne.jp

11

Yamamotoetetal.；The
al.；Theidentification
identification ofof a pharmaceuticalbox
Yamamoto
pharmaceuticalpackaging
packagingbox

calculation requirements in the medical dispensing
fee revisions 1-5). According to the survey conducted2.

Methods

in 2015 by Japan Pharmaceutical Association , the6)

1. Subjects and research methods

average number of medicines in the medicine
inventory was 1,053.9 types

Identification experiments: Subjects were 90

in 818 healththepharmacists who participated in a seminar ofquestionnaire survey. Among the pharmaceutical

Shonan Higashi Area Pharmaceutical Association,

products, the generic products averaged at 278.9.

which was held in Kanagawa Prefecture in March

Stock quantities of 1,000 or more types account for2019.

insurance

pharmacies,

asansweredin

47.4%, almost half, of the total from pharmacies,

Questionnaire surveys: Subjects were 406

700 to 1,000 accounted for 39.6%, and fewer thanpharmacists who participated in seminars held in

700 account for 13.0%. In this circumstance of

Yamaguchi Prefecture in May–July 2019 by Ube

increased stockpiles, storage spaces are limited andPharmaceutical

medical products are placed on shelves above the

Association Academic Lecture, Shimonoseki City

dispensing cabinet and stored in drawers of thePharmaceutical Association, Hofu Pharmaceuticalcabinet. PTP (press through package) sheets of most

Association,

drugs remain in their individual boxes. When

Association, Yamaguchi Society of Hospital

preparing in most pharmacies, pharmacists identify

Pharmacists Pharmaceutical Research Seminar andmedicines depending on product information on the

Hagi Pharmaceutical Association.

Association,

Yamaguchi

City

Shuyaku-kai

Pharmaceuticalshort-sides of package boxes. Our previous research,

These seminars, in which our surveys werewhich was conducted with an aim to prevent

performed, were held for pharmacists without entry

pharmacists from dispensing errors, reported that

restrictions on occupational category, age andwhen a label design on the short-side uses the same

experience.

color on the front side, it was effective to distinguishproduct items 7). The Incident Collection and2. Identification experiments

Analysis Project of “Hiyari-hatto”, close call, in

Subjects moved to a position where they were

Pharmacy 8) reported that a large number ofable to adequately distinguish images displayed ondispensing errors occurred via picking up the wrong

the screen and watched four types of sample sheets

content type from specifications. For items within order. The sample sheets simulated a drawer of amultiple specifications, particularly, effective label

dispensing cabinet, where designs on the short-sides

designs are necessary to help distinguish products.

of rectangular packaging boxes were arranged.

Therefore, we aimed to clarify how design pattern,

Sample sheet Ⅰ: Same design pattern and same color

color, and layout of the package short-sides(Fig. 1-a). Sample sheet Ⅱ: Different design patterns

influence identification for pharmacists, examining

for each article and same color (Fig. 1-b). Sample

distinguishable product information on packaging

sheet Ⅲ: Same design pattern and different colors

boxes from the viewpoint of preventing pharmacists

for each article (Fig. 1-c). Sample sheet Ⅳ:from dispensing errors.

Different design patterns and different colors for22Japanese
JournalVol.8,
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1-12(2020)
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JournalofofCommunity
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Pharmacy Vol.8,
No.1,
1-12
(2020)

a)Sample sheet Ⅰ

b)Sample sheet Ⅱ

c)Sample sheet Ⅲ

d)Sample sheet Ⅳ

Fig. 1

Sample sheets of the designs on short-sides of individual package boxes
used in the identification experimentsa) Sample sheet Ⅰ: Same design pattern and same colorb) Sample sheet Ⅱ: Different design pattern for each articlec) Sample sheet Ⅲ: Different colors for each articled) Sample sheet Ⅳ: Different designs and different colors for each article

each article (Fig. 1-d). Subjects were assigned to

21 articles (63 items) were selected based on usage

identify a designated item on each sheet within thefrequency in pharmacies in descending order. On agiven time, ten seconds; they were shown the

sheet which represented a storage drawer, 1 – 63sample sheets in order. After the experiments, welocation numbers were allocated. Random numbers

counted the number of subjects in a manner ofwere generated for 63 agent item cells employing

raising a hand, when they identified the designatedtheitems. Based on the experimental results, we

numbers were applied from “1” in ascending ordercompared the four ratios of the number of subjects

and then, duplicated numbers were randomized

who identified the item for each sample sheet.

using random numbers which were not overlapped.

RANDBTWEEN

function.

Randomized

The sample sheets were created as follows: As for

After consulting TOYAMA SUGAKI Co., Ltd.

pharmaceutical agents which begin with “ア”, “a”,

regarding designs on the short-sides of packaging
3
3

Yamamotoetetal.；The
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identification ofof a pharmaceuticalbox
Yamamoto
pharmaceuticalpackaging
packagingbox

Fig. 2

Design A

Design B

Design C

Design D

Sample sheets on the short-sides of package boxes used in the questionnaire survey

boxes, font type, position and size were decided

each content specification. Design C: Designin accordance with widely used standard designs.

patterns are different for each article, andThe given time, ten seconds, were from showing to

specifications have different colors for eachhiding a sample sheet in each experiment.

specification but have a common design. Design D:
Design patterns are different for each article and3. Questionnaire surveys

different colors for each content specification but

3.1 Identification of designs on the short-sides ofwith a common design pattern. In the survey,

pharmaceutical package boxes

subjects were asked to rank the four sample sheets

For the questionnaire survey, four different types

which had different design layouts, in terms ofof product designs were employed. The design rule

identification discriminability, and to answer theirwas as follows (Fig. 2). Design A: Design pattern isreasons regarding the first and fourth ranking.

the same for all articles and colors are different for

The designs on the short-sides of packages in theeach content specification. Design B: Colors are

sample sheets were created in the same manner ofdifferent for each article and colors are different for

the identification experiments.
44Japanese
JournalVol.8,
No.1,
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JournalofofCommunity
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Pharmacy Vol.8,
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(2020)(b)(a) the same color for all specifications

(c)

(e)

Fig. 3different colors

different colors and a mark indicatingother specifications

only some parts of design patterns havedifferent colors for each specification(d)different colors and an arrow symbol
indicating other specifications(f)different colors and indications of
all the specifications

Sample sheets of specification designs on the short-sides of packages used in questionnaire survey

3.2 Identification of specification designs on the

distinguishing products easily; six product types

short-sides of pharmaceutical package boxes

had different design layouts for the short-sides of

Six types of specification designs were createdpackages. The subjects were asked for their reasonsfor the short-sides of boxes, in which tablets were

for the first and the sixth ranking. Furthermore, they

supposed to be packed individually. The design

assessed the necessity of the indication for multiple

rules were as follows (Fig. 3). (a): All specifications

specifications, using an assessment scale with four

were shown in the same color. (b): Only some parts

steps; necessary, somewhat necessary, somewhatof the design patterns have different colors for each

unnecessary, and unnecessary.

specification. (c): Colors are different for each

Package designs on the short-sides for sample

specification. (d): Each specification has different

sheets were created in the same manner ofcolors and an arrow symbol which means that theidentification as the experiments.

product is a type with multiple drug concentrations,having other specifications. (e): Each specification

4. Statistical analysis

has a different color and a mark which means that

The manner in which to calculate the scores in thethe drug has other specifications. (f): Eachsurvey regarding the identification for design on thespecification has different colors and indicates all

short-sides of packages was as follows: four points

the specifications that the product has. The

were given to the first position, similarly, threeparticipants were asked to rank the six designs forpoints to the second, two points to the third and one
55Yamamotoetetal.；The
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identification ofof a pharmaceuticalbox
Yamamoto
pharmaceuticalpackaging
packagingbox

point to the fourth. The total scores were obtained.

disadvantage if they did not participate in the

A box-and-whisker plot was created showing the

research, and the obtained information was notquartile range from the median. Multi-analysis was

utilized for any other aims than this research.

performed using the Bonferroni approach. A

Participations in this experiment and replies to thesignificant level was p<0.05/6=0.0083. Furthermore,questionnaires were considered to be the consent on

identification for specification of the box short-research cooperation. This questionnaire survey

sides was assessed. Similarly, six points were given

was implemented with the Ethical Guidelines forto the first position, five points to the second

Medical and Health Research Involving Humanposition, four points to the third position, three

Subjects and conducted under an approval of thepoints to the fourth position, two points to the fifth

Ethics Review Committee on Research of general

position and one point to the sixth position. The

corporate

points were calculated for the total scores. A box-

Pharmaceutical Association (permission number

and-whisker plot was created showing quartile

19-01).

jud icialp erson,Yamaguc hi

range from the median. Multi-analysis was
performed using the Bonferroni approach. A

3.

Results

significant level was p<0.05/15=0.0033. The IBM
SPSS Statistics version23 was employed for a

1. Identification experiments

statistical analysis.

The ratios of the number of subjects who
identified

5. Ethical considerations

thedesignatedproducts

intheexperiments are shown in Table 1. The highest ratio

Research participants in this study were fully

was in sample sheet Ⅲ, whose design was the same

informed about the meaning and contents of thisdesign and different colors for each article.

research. Participations relied on the concept ofindividual autonomy. Furthermore, they wereappropriately

informedthat

2. Questionnaire surveys

confidentiality

The collection rate of this questionnaire survey

pertaining to participants and institutions was

was 100 percent.

secure, and that they would not receive any
Table 1 The ratios of subjects who identified the designated products in Sample sheets Ⅰ–Ⅳ
The number of subjects who identified
the products (n=90)

The ratio of subjects who identified
the products

Sample sheet Ⅰ

26

28.9%

Sample sheet Ⅱ

33

36.7%

Sample sheet Ⅲ

43

47.8%

Sample sheet Ⅳ

34

37.8%

6
6

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JournalVol.8,
No.1,
1-12(2020)
Japanese
JournalofofCommunity
Community Pharmacy
Pharmacy Vol.8,
No.1,
1-12
(2020)

2.1 Identification of designs on the short-sides ofpharmaceutical package boxes
The ranking positions in four designs wereconverted into scores by calculation for total scoresbased on the given points and subsequently,
comparisons of the median values among Design A,
B, C, and D were shown (Fig. 4). As a result, Design
C was significantly high in median values incomparison with the other three designs.
The subjects gave their reasons for their firstranking. For <Design A>, the main reasons of theirchoices were “simple and conspicuous (n=9)”, andFig. 4“specification is easily recognized (n=5)”. Similarly,
the

main

reasonsfor<DesignB>

were“conspicuous (n=42)” and “subjects were able toComparison in identifications among
the four design types on the shortsides of packages

Ranking positions for Design A, B, C, and D of
the questionnaire responses were decided by
calculating the total scores; four points were
given to the first position, three points to thesecond, two points to the third and one point to
the fourth. Aggregating data of questionnaire
responses, four types of designs, A, B, C, and D,
were examined where points 1–4 for the numberof subjects were written for each design. With the
purpose of detecting which point was the highest
among 1–4 points, median values were
calculated. A box-and-whisker plot was createdshowing the quartile range from the median. The
box-and-whisker plot shows that the median isindicated with a horizontal line in the interior ofa box, the bottom line of the box represents thefirst quartile (25%), the top line of the box
represents the third quartile (25%). Both ends ofthe whiskers represent the maximum and theminimum values located within the 1.5 times
length of the box. A white circle (○) outside thewhisker was an outlier. A multi-analysis was
performed using the Bonferroni approach. The
significant level was p<0.05/6=0.0083. The
marks of ＊ shown in Fig. 4 represent
comparisons which were judged to havesignificant differences.

recognize the same article (n=27)”. <Design C>
were “conspicuous (n=65)” and “subjects were able
to recognize that products were classified by each
item and each specification (n=54)”. <Design D>
were “it was good to have a common design (n=9)”
and “articles and specifications were easily
recognized (n=7)”.
The subjects gave their reasons for their fourth
ranking. For <Design A>, the main reasons of theirchoices were “indistinct/hard to distinguish (n=115)”and “a risk of picking-up errors (n=34)”. Similarly,
the main reasons for <Design B> were “as articles
have the same color, specifications seemed to beeasily mistaken (n=12)” and “As the color of theright and left bands is the same, specifications
seemed to be easily mistaken (n=7)”. <Design C>
were “indistinct/hard to distinguish (n=15)” and“information quantity is large (n=4)”. <Design D>
were “as there are common designs, specification
seems to be easily mistaken (n=23)” and“information quantity is large (n=7)”.

7
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Yamamotoetetal.；The
al.；Theidentification
identification ofof a pharmaceuticalbox
Yamamoto
pharmaceuticalpackaging
packagingbox

2.2 Identification of specification designs on the
short-sides of pharmaceutical package boxes
Comparisons of the calculated total scores among
all ranking positions were shown in (Fig. 5). The
median value of design (f) was significantly high incomparisons with other designs.
The subjects gave their reasons for their firstranking. For (a), the main reasons of their choices
were “simple and conspicuous (n=2)”, and “it isbetter not to have specific images (n=1)”. Similarly,(b): “conspicuous (n=7)”. (c): “simple andconspicuous (n=40)” and “specification designs

Fig. 5catch attentions (n=8)”. (d): “all specifications arerecognized/it is able to notice that the article hasother specifications (n=12)” and “simple mark of

Comparison in identifications amongsix design types on the short-sides of
packages

The ranking positions for (a)–(f) in thequestionnaire responses were decided by
calculating the total scores; six points were given to
the first position, five points to the second position,
four points to the third position, three points to thefourth position, two points to the fifth position and
one point to the sixth position. Aggregating data of
the questionnaire responses, six types of designs
were examined where points 1–6 for the number ofsubjects were written for each design. With the
purpose of detecting which point was the highest
among 1–6 points, median values were calculated.
A box-and-whisker plot was created showing thequartile range from the median. The box-andwhisker plot shows that the median is indicated witha horizontal line in the interior of a box, the bottom
line of the box represents the first quartile (25%),
the top line of the box represents the third quartile(25%). Both ends of the whiskers represent the
maximum and the minimum values located within
the1.5 times length of the box. A white circle (○)
outside the whisker was an outlier. A multi-analysis
was performed using the Bonferroni approach. The
significant level was p<0.05/15=0.0033. The marksof ＊ shown in Fig. 5 represent comparisons whichwere judged to have significant differences.

arrows is a good d esig n (n=5 ) ”. (e ): “allspecifications are recognized/it helps to notice thatthe article has other specifications (n=52)” and“conspicuous (n=23)”. (f): “all specifications arerecognized and it helps to notice that the article hasother specifications (n=150)” and “conspicuous(n=25)”._____________________________The subjects gave their reasons for their sixth
ranking. For (a), the main reasons of their choices
were “a risk of picking-up errors due to the samecolor (n=249)” and “There would be a large numberof picking up wrong specifications (n=41)”. (b):“colors are not conspicuous (n=6)” and “figures
look small due to color classification (n=1)”. (c): no
answer. (d): “marks are confusing (n=2)”. (e):“marks are confusing (n=1)”, (f): “no need forindication of other specifications (n=3)” and“jumble (n=1)”. ______________________The subjects answered a question on whether or“somewhat necessary (n=155: 38%)”, “somewhat

not indication for other speculations is necessary,

unnecessary (n=26: 6%)”, “unnecessary (n=9: 2%)

using an assessment scale with four steps. The

and “blank (n=11: 3%)”.

survey results were “necessary (n=205: 50%)”,88Japanese
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emphasized. Consequently, the subjects were able
4. Discussion

to identify the designated item within a shorter time,as this study suggested. Judging these results, it wasThis study performed identification experimentssuggested that information based on colors andand questionnaire surveys to clarify how designs,

layout with emphasis on specification indications

colorsofgreatly influenced identification. The experiments

pharmaceutical packaging boxes, in which tabletsof this study observed that color for each article waswith press through packages (PTP) were contained

more effective than design patterns for each article

individually,

to

and

layouts

pharmaceuticalonaffectedthetheidentification

distinguishproducts.

Furthermore,theexperiments observed that for distinction ofexperiments were assigned a time limit and subjects

products, the effectiveness of both colors and design

were assigned to identify items within the given

patterns was the same as design patterns alone. Antime, simulating to open a drawer in a dispensing

appropriate quantity of information must be

cabinet in a pharmacy and prepare drugs as quickly

considered to identify a pharmaceutical product asasquickly as possible from a large number of products

duringTheofidentification

possible

products.

short-sides

dispensing

activities.

Subsequently, the achievement ratios for four

stored in a drawer of the cabinet.

sample sheets were compared regarding the number

The questionnaire survey for 406 researchof subjects who found the designated products

participants provided adequate time for thewithin the given time. The experimental results

pharmacists to consider and answer questions,were as followed: The ratio for sample sheet Ⅰ was

unlike the experiments, in which a participant may

28.9%, where one color and one design pattern werefeel hurried due to a time limit. Identifications ofused. Sample sheet Ⅱ ratio was 36.7%, where one

information on the short-sides of pharmaceuticalcolor was used but every article had corresponding

packaging boxes were examined via this survey

design patterns. This suggested that design patterns

where participants were able to judge without hurry.

influenced identification. Furthermore, the ratio in

The compared identifications of four design types

sample sheet Ⅳ, where in addition, different colors

on the short-sides of packages showed that Designfor each article are used to distinguish articles, wasC had a significantly high median value; not only

37.8%. This result of sample sheet Ⅳ was almost

design patterns were different for each article but

equivalent to that of sample sheet Ⅱ. The

also colors were different for each specification.

achievement ratio of sample sheet Ⅲ, where design

The results of the survey confirmed that Design C

patterns are identical and colors are different

was chosen as the most distinguishable design. The

corresponding

47.8%.

main reasons that Design C was most easily

Approximately half of the subjects were able to findidentified were “conspicuous”, and “subjects were

the designated item for sample sheet Ⅲ. Althoughable to recognize that products were classified bysample sheet Ⅲ had as simple a design pattern aseach article and each specification”. These answers

sample sheet Ⅰ, not only articles are distinguishedaccounted for approximately 30% (119 in 406

due to band but also content size specifications are

subjects). It was suggested that Design C enabled

to

each

articlewas

99Yamamotoetetal.；The
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Yamamoto
pharmaceuticalpackaging
packagingbox

the prevention of dispensing errors regarding wrong

specifications most distinctively. The main reasonscontent

thethat the specification design of (f) was best, were

pharmaceutical“all specifications are recognized” and “it helps to

products, because of not only a distinguishable

notice that the article has other specifications”. The

design to recognize the same article but also

ratio of these reasons was approximately 43% (175effective color classifications on specificationin 406 subjects). It was suggested that indications of

indications. Design B gained the second highest

multiple specifications enabled subjects to cognize

scores next to Design C. The reasons for the choice

the presence of other specifications and be moreof Design B were “conspicuous” and “subjects werecautious in distinctions of specifications. As a result,able to recognize the same article”, as a large

the design (f) is effective to prevent dispensing

number of participants answered. However, “aserrors, as was considered. When pharmacists know

articles have the same color, the specifications

the presence of other specifications, and find that

seemed to be easily mistaken” was observed in asome products are not prepared in the institution

large number of answers to Design B. From these

they belong to, they could suggest new prescriptions.

viewpoints, it is required to develop ingenuity on

Furthermore, the questionnaire regarding thedesign including color classifications corresponding

necessity of the indications of multiple typeto articles and color layout for indications ofspeculations confirmed that 50% of the subjects,

specification parts. The present research showed thepharmacists, answered “necessary”. Including theparticipants nine pharmaceutical product items in aanswers of “somewhat necessary”, 88% ofmanner of three articles and three specifications andpharmacists in the survey found a necessity of

they were able to afford the time to consider theindications for multiple-type specifications. The

items. Consequently, this research suggested thatstudy of Sato et al. 9) regarding PTP sheets reported

both design- and color-related distinctions based onthat dispensing errors occurred frequently inarticle types enhanced identifications of participants

pharmaceutical products with two specifications

in comparison with color-related distinction based

compared with that with single specification. Thus,onrequirethe identification of specifications is an important

examinations and verifications to develop design

factor to reduce risk factors of picking up errors.

methods for the usages of colors and layouts

The present study employed three types offocusing on specification parts and to observe how

indication methods for multiple specification types:

identifications are affected in practical settings of“arrow

pharmacies via experimental methods.

specification mark: sample sheet (d)”, “large,

types

identification

articleofoftypes.

thespecifications,correct

Furtherstudiesandsymbols

placedover

and/orunder

Next, (f) obtained the significantly highest

medium and small circle symbols: sample sheet (e)”median values as the identification of specification

and “all specifications are inscribed: sample sheet

in the questionnaire survey. In this design (f), colors(f)”. It is considered that symbols such as arrow andare different based on the content quantity type andcircle symbols are unlikely to convey our intentions

all specifications are indicated in the layout designs,

if they are not accompanied by written explanations.

which resulted in subjects’ choice to identify

We continue to examine distinctions of symbols,
1010Japanese
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JournalofofCommunity
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balancing in whole information and coloring

the institutions involved in this research for their

methods to develop effective indication methods

time and commitment. This work was supported bywhich enhance indications of pharmaceutical

public interest incorporated association Kanagawa

products.

Pharmaceutical Association, general corporate

This study confirmed that the color-related

judicial

personYamaguchi

Pharmaceuticalclassification based on articles was supportive in

Association (Shimonoseki City Pharmaceuticalregard to identification of articles. However, it was

Association, Ube Pharmaceutical Association, Hofu

suggested that approaches to identify differences inPharmaceuticalspecifications are required using not only coloring

Pharmaceutical Association, Hagi Pharmaceuticalmethods but also design pattern methods. In

Association,

addition, it was suggested that display methods

Association), and Yamaguchi Society of Hospitalwere necessary to enable pharmacists to perceive

Pharmacists.

Association,andTokuyama

Yamaguchi

City

Pharmaceutical

the presence of other specifications. Sato et al. 9)
also have suggested similarly, regarding design

Conflicts of Interest：COI

studies of PTP sheets with different specifications.
Most pharmacists considered that identifying

Kohei Miyaso is an employee of Toyama Sugaki

specifications

Co., Ltd.

wereparticularly

significant.

Furthermore, dispensing errors due to mistaken
identification

regardingspecifications

have

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Acknowledgement

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identification ofof a pharmaceuticalbox
Yamamoto
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