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, et al. Patient safety in surgery. 2015;9:12.

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.