USP Quality Review

No. 78, Issued February 2004

Too Much Similarity

Similar Labeling/Packaging

Potential error: The facility ran out of labetalol, which required them to purchase some from a neighboring hospital. The neighboring hospital carried a different brand of labetalol (manufactured by Abbott) than the facility normally stocked. The facility realized that the labeling of the Abbott brand of labetalol looked similar to A.H. Robins' Dopram® when the vials were placed next to each other on an anesthesia cart. Dopram is indicated for respiratory depression and labetalol is for hypertension.
Reporting pharmacist's action/recommendation: To prevent this potential medication error from occurring, the facility removed the look-alike labetalol and replaced it with the brand they usually purchase.


Photo of Dopram & labetalol similar labeling/packaging*

Potential error: The labeling of Geodon™ (manufactured by Pfizer) 20 mg and 60 mg tablets is similar. The pharmacist was verifying an order for a total dose of 80 mg. The order was filled with a 20 mg and 60 mg tablet, and had a sticker attached that read, "note the dose" to indicate that both tablets should be administered. At first glance, the pharmacist believed the order was filled wrong and that they were both 60 mg tablets.
Reporting pharmacist's action/recommendation: The facility took several actions to avert mix-ups: The pharmacist (1) notified staff, (2) initiated use of cautionary stickers on the unit-dose package, (3) added a warning in the computer system, and (4) separated the two products on the shelves.


Photo of Geodon 20 mg & 60 mg similar unit-dose packaging*

Error description: A pharmacy technician noticed that a lorazepam Carpuject® (for anxiety disorders) was returned to the pharmacy and placed in the diphenhydramine (for allergic symptoms) bin. Both products are manufactured by Abbott. Upon further investigation, it was realized that the Carpujects have green caps and look very similar to each other.
Reporting pharmacist's action/recommendation: The manufacturer should consider changing the color of the caps on the Carpujects as well as changing to a different color for the drug name.

Photos of diphenhydramine & lorazepam similar Carpuject packaging*

Error description: Falcon Pharmaceuticals timolol 0.5% and levobunolol 0.5% ophthalmic solutions (both used for the treatment of intraocular pressure) have very similar packaging and were found in the same location on the pharmacy shelf. The label, dose, size, and even color of the boxes are nearly identical. Both products were received from the wholesaler on the same day. It is believed that a technician assumed they were the same product and placed them together on the shelf; the levobunolol's normal location is on a separate shelf. The pharmacist caught the error when one product was being labeled for dispensing.
Reporting pharmacist's action/recommendation: The facility has purchased a different brand of levobunolol to avoid future mix-ups.


Photo of timolol and levobunolol similar labeling/packaging*

Error description: A technician filling an order for heparin (manufactured by American Pharmaceutical Partners) noticed that a vial of glycopyrrolate (manufactured by American Regent Laboratories) was in the heparin bin. Heparin is for thromboembolic disorders and glycopyrrolate inhibits salivation and excessive secretions. The reporter thinks that, although the names are different, the vials are nearly identical in color and in a big bin they can be easily confused. The tops are the same color purple and the labeling has the same purple on white. The only difference is that the glycopyrrolate has the words "flip off" in raised letters on the top.
Reporting pharmacist's action/recommendation: It turns out, the facility usually orders the 1 mL glycopyrrolate vial; this error occurred with the 2 mL vial. The facility plans to purchase only the 1 mL glycopyrrolate vial in the future.


Photo of glycopyrrolate & heparin similar labeling/packaging*

*Provided courtesy of the reporter or the Institute for Safe Medication Practices.