USP Quality Review

No. 78, Issued February 2004

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Too Much Similarity

The following error descriptions and recommendations are summarized from reports received through the USP Medication Errors Reporting (MER) Program during the time period July—September 2003. These cases illustrate how the similarity in product labeling and packaging and the drug product itself can lead to errors or have a potential to cause errors. When reading these examples, it may be apparent to the reader that the products differ; but in a busy work environment where there can be many distractions, it is easy to mistake these products for one another.

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The USP Quality Review is a publication of the USP Center for the Advancement of Patient Safety. Online reporting to the USP Medication Errors Reporting Program is available through the Internet at www.usp.org/patientSafety/mer/. Forms can also be printed at this Web site or requested by calling 1-800-23-ERROR (1-800-233-7767). The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.