Innovative medical device packaging to minimise user error


Find an alternative packaging solution to reduce error when using medical devices.


We took a book-like approach to medical device packaging based on the Japanese concept of ‘poka-yoke’. Drawing sketches and using our ergonomics experience helped us consider all possible error when handling a medical device for the first time.


The result was a step-by-step packaging solution for an insulin pen with clear graphical instructions that removed the need for costly product design.

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Following a number of user studies which showed that users make more mistakes if they are given all the components of a device at the same time with only paper instructions for guidance, we developed a novel approach to packaging to attempt to alleviate this problem.

Working with packaging manufacturer Burgopak, our concept was developed into a fully functioning prototype, applying the Japanese principles of ‘poka-yoke’.

Poka-yoke, which means ‘mistake-proofing’, is a design concept that originated in 1960s Japanese manufacturing and aims to prevent human error.

Our approach

We began by considering what errors could occur during first use of a medical device.

‘Poka-yoke’ packaging to minimise user error

These sketches developed into the idea of presenting step-by-step instructions as you opened the packaging, each step helping to give you the information in the correct order.

‘Poka-yoke’ packaging to minimise user error


Rather than relying on paper instructions for use (IFU) and user intuition, our poka-yoke packaging presents users with each part of the device in order, with clear graphical instructions on how to construct and use the device at every stage.

This ensures users cannot put the wrong pieces together or miss out key steps. By applying poka-yoke principals to packaging, we hope this could remove some of the fear and anxiety patients experience when using a medical device – and avoiding the need for time-consuming and costly design overhauls of the products themselves.

The outcome is a packaging concept for an injection pen device (such as an insulin pen) which aims to educate users in a step-by-step way.

‘Poka-yoke’ packaging to minimise user error
poka yoke packaging concept outcome
‘Poka-yoke’ packaging to minimise user error

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