Case report of a medication error: in the eye of the beholder. | AHRQ Patient Safety Network

Case report of a medication error: in the eye of the beholder. | AHRQ Patient Safety Network

• Commentary
 
• Published July 2016

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

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