How to Prevent Look-Alike Packaging Confusion in Pharmacy Settings

Every year, thousands of patients in the U.S. receive the wrong medication-not because of a doctor’s mistake, not because of a nurse’s oversight, but because two pills look too much alike on the shelf. One bottle says hydralazine, another says hydroxyzine. One label reads DOPamine, another DoBUTamine. To the untrained eye, they’re nearly identical. And in a busy pharmacy, where staff are juggling dozens of prescriptions at once, that tiny difference can be deadly.

This isn’t rare. According to the Institute for Safe Medication Practices (ISMP), about 18% of all medication error reports involve look-alike or sound-alike (LASA) drugs. That’s roughly 10,000 incidents annually. And it’s not just names. Packaging plays a huge role. Similar colors, fonts, bottle shapes, and label layouts make it easy to grab the wrong thing-even for experienced pharmacists.

Why This Problem Still Exists

Look-alike packaging confusion isn’t new. The Joint Commission flagged it as a national patient safety goal back in 1999. But despite decades of awareness, the problem persists. Why? Because many pharmacies still rely on human memory and visual scanning to pick drugs. And humans aren’t good at spotting tiny differences under pressure.

Consider this: a retail pharmacist might fill 80 prescriptions in a single shift. In that rush, they grab a bottle from a crowded shelf. The label is the same size. The font is the same. The color scheme? Identical. The only difference? One letter. In uppercase. Hidden in the middle of a long word. That’s not a design flaw-it’s a recipe for disaster.

And it’s not just community pharmacies. Hospitals face the same issue. Insulin vials, heparin syringes, sedatives, and antibiotics often come in near-identical packaging. One wrong dose can lead to cardiac arrest, respiratory failure, or death.

The Three Proven Strategies That Work

There’s no single fix. But when you combine three evidence-based strategies, error rates drop dramatically. Here’s what actually works.

1. Physical Separation: The Simplest, Most Effective Fix

Put look-alike drugs far apart. Not just different aisles-different cabinets, different drawers, different shelves. The University of Arizona found this reduces errors by up to 62%. That’s not a small win. That’s life-saving.

It doesn’t require fancy tech. A simple plastic divider, a colored shelf tag, or even a sticky note saying “HIGH RISK-DO NOT GRAB WITHOUT DOUBLE-CHECK” can make a difference. One pharmacy in Arizona separated all insulin types into locked, labeled drawers. Within 18 months, wrong-insulin errors dropped from 3-4 per month to zero.

But here’s the catch: space is tight. Many pharmacies, especially small ones, don’t have room to spread everything out. That’s okay. You don’t need a whole new layout. Use existing storage wisely. Keep high-risk pairs like spironolactone and spiramycin on opposite ends of the same shelf. Use vertical space. Add risers. Use drawer dividers. Even $300 in shelf organizers can cut errors by half.

2. Tall Man Lettering: Make the Difference Visible

Tall Man Lettering (TML) isn’t a trick. It’s a visual cue. Instead of writing “dopamine” and “dobutamine,” you write DOPamine and DoBUTamine. The capital letters force your brain to pause and notice the difference.

ISMP’s research shows TML reduces selection errors by 47%. The FDA recommends it for over 100 high-risk drug pairs. And it’s free-once your pharmacy system supports it.

But here’s where it breaks down: not all systems do it right. Some EHRs only apply TML to the name on the screen. Others don’t print it on the label. One pharmacist in Ohio told us they spent weeks troubleshooting because the label printer ignored TML settings. The fix? Work with your vendor. Ask for a custom print template. Test it. Print a sample. Make sure the uppercase letters show up on the final label.

And don’t forget new drugs. Every time a new medication arrives, check if it looks or sounds like anything already in stock. ISMP updates its list of confused drug pairs quarterly. In January 2024, they added 17 new pairs-including buprenorphine and butorphanol. If you’re not checking, you’re not protected.

3. Barcode Scanning: The Last Line of Defense

Barcode scanning is the most powerful tool. When a pharmacist scans the drug, the system checks it against the prescription. If it doesn’t match? It alerts them. Immediately.

The Agency for Healthcare Research and Quality (AHRQ) found barcode scanning reduces administration errors by 86%. That’s the biggest single improvement you can make.

But here’s the problem: people bypass it. Nurses swipe the barcode without looking. Pharmacists scan the wrong bottle. One study at UC San Francisco found 5-12% of scans were skipped or done incorrectly.

The fix? Make scanning mandatory. Tie it to your workflow. No scan? No release. Add a checklist. Train staff to treat it like a seatbelt-something you do without thinking. And monitor compliance. Track how often scans are skipped. Reward teams that get it right 99% of the time.

What Doesn’t Work (And Why)

Some pharmacies try to solve this with posters. Or mnemonics. Or “be more careful.”

That’s not enough.

Dr. David Bates from JAMA Internal Medicine put it bluntly: “Over-reliance on Tall Man Lettering creates a false sense of security.” Why? Because TML only fixes name confusion. It doesn’t fix packaging. Two bottles can still look identical-even if the names are in different cases.

And staff education alone? It helps, but it’s not reliable. People get tired. They get distracted. They’re human. Systems should protect them-not expect them to be perfect.

How to Get Started Today

You don’t need a million-dollar budget. Start small. Here’s how.

1. Do a quick LASA audit. Grab ISMP’s free Tool for Evaluating the Risk of Confusion Between Drug Names. Spend 2 hours listing your top 10 most confusing pairs. Common ones: clonidine and clonazepam, fluoxetine and fluvoxamine, hydroxyzine and hydralazine.
2. Separate the top 3. Move them to different shelves or drawers. Use colored tape or labels. No cost. Immediate impact.
3. Check your EHR. Does it use Tall Man Lettering on labels? Print a sample. If not, contact your vendor. Ask for a custom template. Demand it.
4. Enforce barcode scanning. If you have scanners, use them. If you don’t, prioritize getting them. Even a basic handheld scanner costs under $200. The ROI? One prevented error pays for it ten times over.
5. Create a daily checklist. Add “Verify LASA drugs” to your shift handover. Make it part of the routine.

What’s Coming Next

The FDA just released draft guidelines in February 2024 requiring standardized Tall Man Lettering for 25 new high-risk drug pairs. The National Council for Prescription Drug Programs (NCPDP) is building a universal LASA data format set to launch in late 2025. That means in a few years, every pharmacy system will automatically flag look-alike drugs-no manual work needed.

Meanwhile, AI is stepping in. Pilot programs at Johns Hopkins use machine learning to scan packaging images and flag potential look-alikes before a drug even hits the shelf. Accuracy? 98%.

This isn’t science fiction. It’s the future. And it’s coming fast.

Final Thought: Safety Is a System, Not a Wish

Preventing look-alike packaging errors isn’t about being more careful. It’s about designing systems that make mistakes nearly impossible.

Physical separation. Tall Man Lettering. Barcode scanning. These aren’t optional upgrades. They’re the bare minimum. And if your pharmacy isn’t using all three, you’re gambling with lives.

One wrong pill can end a life. But one smart system can save thousands.