1. Shastay, Ann MSN, RN, AOCN

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Look-alike Packaging

Ophthalmic ointment tubes of Bausch + Lomb neomycin and polymyxin B sulfates and bacitracin zinc are nearly indistinguishable from the company's erythromycin 0.5% ophthalmic ointment; even their outer cartons look similar (Figure 1). These products may be stored near one another in a pharmacy's ophthalmic section. Both products are used to treat superficial ocular infections, but erythromycin 0.5% ointment is the only drug approved by the Food and Drug Administration (FDA) for the prevention of gonococcal ophthalmia neonatorum. A dispensing error-for example, the triple antibiotic ointment dispensed instead of the erythromycin ointment-may not be easily recognized given the small container size with tiny, hard-to-read print.

Figure 1 - Click to enlarge in new windowFigure 1. Bausch + Lomb ophthalmic ointment tubes of neomycin, and erythromycin (top front of tubes; middle: back of tubes) look very similar, as do their outer cartons (bottom).

We have previously published our concern with the ophthalmic product color-coding system approved for use by the American Academy of Ophthalmology ( and tacitly approved by the FDA ( because it results in mix-ups between ophthalmic products. Blue is supposed to be reserved for use with beta blockers, whereas the color tan should be used for antibiotics. However, these Bausch + Lomb antibiotics prominently use blue in horizontal bands on both the tube and outer carton, but only display a narrow, tan vertical band on the cartons and tubes.


We also received reports of look-alike phenylephrine hydrochloride, atropine sulfate, and tropicamide ophthalmic solutions from Akorn Pharmaceuticals. These drugs fall into the red color-code category used to differentiate mydriatics and cycloplegics from other ophthalmic products. The red and white box, with a black band across the top, and the product concentration highlighted in red (Figure 2) contribute to the similar appearance of these containers.

Figure 2 - Click to enlarge in new windowFigure 2. Cartons of phenylephrine hydrochloride, atropine sulfate, and tropicamide ophthalmic solutions from Akorn Pharmaceuticals appear nearly identical.

One strategy to prevent mix-ups is for pharmacies to purchase products from different manufacturers to reduce look-alike containers. Storing ophthalmic products intermingled with the rest of the pharmacy inventory, rather than in their own section, might be of benefit. When dispensing these products, careful visual product verification is key in preventing mix-ups, and barcode scanning prior to dispensing is a must. Prior to administration, ensure the correct medication is in hand.


Look-alike Cartons for Topical Creams

We have received reports about two topical products that have nearly identical packaging. While checking in a shipment of products, a pharmacy worker initially thought he had two cartons of the same product but, they were two very different drugs. In one hand he held the local anesthetic cream lidocaine 2.5% and prilocaine 2.5%. In the other hand, he had clobetasol 0.05%, a topic corticosteroid. The manufacturer for both products, Teligent Pharma, Inc., uses the same colors, layout, design, and package size for the two topical products, making it easy to confuse them (Figure 3).

Figure 3 - Click to enlarge in new windowFigure 3. Lidocaine and prilocaine (top and middle) and clobetasol (bottom) cartons look similar in color, design, and size increasing the risk of mix-ups.

ISMP recommends a process to ensure all new products are proactively evaluated by practitioners who may use them, looking at the actual packages before drugs are added to inventory. Look-alike products should be purchased from different manufacturers if possible, or steps to avoid a mix-up should be established (e.g., separate storage, warning labels) before the drug is stored and dispensed. Prior to administration, confirm the correct medication is in hand.


Reconstitution with Alcohol instead of Water

We received a report about a bottle of valGANciclovir powder for oral solution that was accidentally prepared using isopropyl alcohol 70% instead of water. The reconstituted product was dispensed, and one dose was administered to a child. The child's parents were contacted and fortunately the child showed no adverse effects. Investigation uncovered two different labels on the bottle of isopropyl alcohol used-one read "isopropyl alcohol 70%" and the other "distilled water." The bottle containing isopropyl alcohol had been prepared and labeled in the pharmacy, using a labeled container that previously contained distilled water.


ISMP has received similar reports in which a solution was stored in reused bottles that previously contained a different substance, but the prior label had not been removed. Other events involved selecting a similar-looking bottle that contained an unintended substance. In one case, a pharmacist reconstituted AMOXIL (amoxicillin) suspension with a 50% alcohol and water solution instead of water. Both containers were on a counter beside each other. The pharmacist accidentally grabbed the alcohol solution.


We have received reports with serious outcomes. Antibiotics were reconstituted with 10% formalin solution (3% formaldehyde and 15% methanol) in two pharmacies that stocked gallon jugs of both distilled water and 10% formalin. Empty jugs labeled "distilled water" were accidentally grouped with empty jugs labeled "formalin" that were awaiting refill. After incorrectly filling all the jugs with formalin, the containers labeled "distilled water" were returned to stock next to distilled water. Later they were used to reconstitute antibiotic suspensions. More than 35 children took the tainted antibiotics. Several were admitted to the hospital for excessive vomiting, but none suffered permanent injuries.


If an oral liquid medication looks or smells different than expected, check with the pharmacy to ensure it was prepared correctly.