How to Prevent Look-Alike Packaging Confusion in the Pharmacy

Every year, thousands of patients in the UK and US receive the wrong medication-not because of a mistake in prescribing, but because two drugs look too much alike on the shelf. A vial of heparin next to a vial of saline. A box of spironolactone sitting beside spiramycin. At a glance, they’re nearly identical. And in a busy pharmacy, especially during rush hours, that’s all it takes for a deadly error to happen.

Why Look-Alike Packaging Is a Silent Killer

It’s not just about names that sound alike-like hydralazine and hydroxyzine. The real danger comes from packaging that tricks the eye. Similar bottle shapes, identical colour schemes, matching font sizes, and even the same placement of warning stickers can make two completely different drugs look like twins. The Institute for Safe Medication Practices (ISMP) says about 20% of all medication errors stem from confusing packaging, not just confusing names. In the US alone, these errors contribute to around 7,000 deaths each year. That’s more than car accidents involving teens. And it’s entirely preventable.

In the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) has flagged this as a top-priority safety issue since 2020. But while hospitals have made progress, community pharmacies-especially small, high-volume ones-are still playing catch-up. The problem isn’t lack of awareness. It’s lack of consistent action.

Physical Separation: The Simplest Fix That Works

You don’t need fancy tech to start reducing errors. The most effective first step? Move the confusing drugs apart.

At a hospital in Bristol, pharmacists noticed they were accidentally pulling insulin glargine instead of insulin lispro three to four times a month. Both came in similar white plastic pens with blue caps. The solution? They moved insulin glargine to a dedicated shelf in the back, marked with a red border and a bold sign: “INSULIN GLARGINE - LONG-ACTING - DO NOT CONFUSE.” Within 18 months, the errors dropped to zero.

Physical separation doesn’t have to cost much. Shelf dividers from a medical supply vendor cost under £50. You can use coloured tape, sticky labels, or even just reorganising the storage layout. The University of Arizona found that separating look-alike drugs reduced errors by 62%. That’s not a guess-it’s data. And it works even when staff are tired, rushed, or distracted.

But here’s the catch: it only works if you do it consistently. If you move insulin glargine to the back today, but put it back next to lispro next week because “we’re out of space,” you’re back to square one. Make separation part of your daily checklist. Train new staff on it. Put it in your standard operating procedures.

Tall Man Lettering: Make the Differences Impossible to Miss

When two drug names are almost the same-DOPamine and DoBUTamine, for example-the brain fills in the gaps. It sees what it expects to see. Tall Man Lettering (TML) forces the eye to pause and read the difference.

TML uses uppercase letters to highlight the part of the name that differs. So instead of writing “Dopamine” and “Dobutamine,” you write “DOPamine” and “DoBUTamine.” It sounds small. But studies show it cuts selection errors by 47%. The FDA recommends it for over 100 high-risk drug pairs. ISMP updates their list quarterly, and in January 2024, they added 17 new pairs, including buprenorphine and butorphanol.

But here’s the problem: not all systems display TML the same way. If your electronic health record (EHR) shows “Dopamine” but the pharmacy label says “DOPamine,” the pharmacist sees a mismatch. That’s worse than no TML at all. In a 2022 survey, 43% of pharmacists said inconsistent TML formats caused confusion during patient handoffs.

Fix this by standardising. Ask your EHR vendor to enable TML across all screens. Print labels with TML using your pharmacy software. If you’re using paper labels, print them with the correct formatting. Don’t rely on someone to remember to capitalise letters manually. Automate it. And if your system doesn’t support it? Push back. This isn’t optional-it’s a safety requirement under The Joint Commission’s Standard MM.05.01.09.

Barcode Scanning: The Final Safety Net

Physical separation and TML help prevent errors before they happen. But barcode scanning catches the ones that slip through.

When a pharmacist scans a medication before dispensing, the system checks: Is this the right drug? The right patient? The right dose? The right time? If there’s a mismatch, it alarms. A 2021 AHRQ report found that full barcode implementation reduces medication administration errors by 86%. That’s not a minor improvement-it’s life-saving.

Some pharmacies skip this because it costs £15,000-£50,000 to install. But you don’t need to go all-in at once. Start with high-risk areas: anticoagulants, insulin, opioids, chemotherapy. Use a handheld scanner for those. If you’re using automated dispensing cabinets (ADCs), make sure they’re set to require a scan before release. And if staff are bypassing the scan? That’s not a tech problem-it’s a culture problem.

At Mayo Clinic, they made scanning mandatory and added daily audits. In 12 months, they eliminated 100% of potential errors with heparin and saline. That’s not luck. That’s discipline.

Label Design: Don’t Let Packaging Betray You

Packaging isn’t just about the bottle. It’s about the label. The font size. The colour contrast. The placement of the drug name versus the strength.

The FDA’s 2021 guidance says labels must be designed to reduce visual confusion. That means:

• Drug names must be the largest text on the label
• Strength must be clearly separated from the name, not tucked in the corner
• Avoid using all caps for the entire drug name-it makes everything look the same
• Use colour coding only if it’s consistent across all products (e.g., red for high-alert meds)

Many generic drugs come with labels designed by manufacturers who care more about cost than clarity. If your pharmacy receives a new generic version of a drug that looks too similar to another, flag it. Don’t just accept it. Contact the supplier. Ask for a revised label. Or, if needed, switch to a different manufacturer. Your patients’ lives depend on it.

Staff Training and Culture: The Human Element

Technology helps. But people prevent errors.

A 2023 survey found that 78% of pharmacy directors say staff resistance is the biggest barrier to implementing safety measures. Why? Because change is hard. Because “we’ve always done it this way.”

Fix this by making safety part of your daily rhythm. Start every shift with a 5-minute huddle: “Today, watch out for spironolactone and spiramycin.” Put up posters in the dispensing area showing the top 5 look-alike pairs in your pharmacy. Run monthly drills: “What would you do if someone asked for ‘DOPamine’ but the label says ‘Dopamine’?”

And reward vigilance. If a tech catches a mislabelled bottle before it goes out, thank them publicly. Make it part of your quality assurance checklist. When people feel their attention matters, they pay attention.

What to Do Right Now

You don’t need to fix everything tomorrow. But you need to start today. Here’s your 30-day action plan:

1. Download ISMP’s 2024 List of Confused Drug Names. Highlight the ones you stock.
2. Walk through your pharmacy. Find any two drugs that look similar. Move them apart.
3. Check your labels. Are drug names in Tall Man Lettering? If not, update your printing templates.
4. Set up a daily scan for high-risk drugs-even if you have to buy a £200 handheld scanner.
5. Hold a team meeting. Show them the data. Say: “We’re not going to let someone get the wrong drug because we didn’t look closely enough.”

The goal isn’t perfection. It’s progress. One less error. One less family broken by a preventable mistake.

What’s Next? The Future Is Here

New tools are coming. AI systems at Johns Hopkins can now scan images of drug packaging and flag look-alike pairs before they even hit the shelf. The National Council for Prescription Drug Programs (NCPDP) is rolling out a standardised LASA data format by late 2025, so pharmacies will automatically get alerts when new drugs are added that match existing ones.

But none of that matters if you don’t do the basics now. Physical separation. Clear labels. Barcode scans. Staff awareness. These aren’t new ideas. They’re proven. And they work.

The next time you pick up a bottle, pause. Look at it like you’ve never seen it before. Ask: Could this be mistaken for something else? If the answer is yes-you’ve just saved a life.