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

Mark Naunton; Kowsar Nor; Andrew Bartholomaeus; Jackson Thomas; Sam Kosari

Commentary

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

August 31, 2016

Naunton M, Nor K, Bartholomaeus A, et al. Medicine (Baltimore). 2016;95(28):e4186.

View more articles from the same authors.

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

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