Boots recall prompts calls for on-line print to cut pharma risks due to human error

Wrongly-identified painkiller foil used on the blister-pack machine of a supplier led to the recall of 110,000 cartons and highlights the benefits of on-line options, says Domino.

While the Boots cartons were correctly printed with the information for 500mg paracetamol tablets, the blister foil inside the pack identified the contents as 300mg dispersable aspirin tablets. Supplier Aspar Pharmaceuticals has launched a full investigation, according to the BBC. The problem was first highlighted in early March.

Bart Vansteenkiste, global sector manager for life sciences at Domino Printing Sciences, makes the point that the failure was most probably the result of human error.

“This is an easy mistake to make when using pre-printed blister foils that typically all look very similar,” he says. “Often, the only difference is the name of the medicine, making it relatively easy for operators to pick the wrong roll and mount it on a blister-packaging machine. What many manufacturers may not know is that this type of error can be easily avoided by printing foils on-line rather than holding pre-printed stock.”

Domino encourages customers to start from blank foils and print the product information, batch code, and expiry dates on-line as part of the packaging process. “As packaging lines in pharma go through a strict validation process, it is impossible to start packaging paracetamol and then print aspirin on the blister foil,” says Vansteenkiste.

On-line blister printing combined with automated machine vision will ensure that the information on the printed foils matches that on the outer packaging, Domino emphasises. The machine vision system will catch any inconsistencies or errors in the packaging, and implement an automatic stop to prevent affected products from leaving the manufacturing line.

“We also recommend printing unique 2D codes on the blister packaging to allow hospital and healthcare staff to double-check medicines before they are taken by a patient,” Vansteenkiste adds.

Systems used to print blister foils as part of the packing process include Domino’s K600G piezo   drop-on-demand digital unit, which has been extensively trialled with a South African pharmaceuticals manufacturer.

Labelling mistakes due to human error remain a common reality across many industries, says the coding and marking supplier. The UK Food Standards Agency recently revealed that the top cause of food-product recalls in 2024 was undeclared allergens due to labelling errors. But while this type of mistake is most common in food and beverage, even heavily-regulated sectors such as pharmaceuticals are not immune, it points out.

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