Journal Article
Commentary

Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.

Schnoor J; Rogalski C; Frontini R; Engelmann N; Heyde CE.

Look-alike sound-alike medications can contribute to confusion and result in drug administration errors. This commentary illustrates how switching to a generic brand of medication to save costs was a factor in recurring underdosing errors. The authors provide recommendations to improve the safety of stocking medications.