Every year in the U.S., around 10,000 medication errors are reported because two drugs look too similar on the shelf. One pill bottle might have a red cap, another a blue one-but if the font, size, and color scheme are nearly identical, a pharmacist grabbing the wrong one during a busy shift isn’t a mistake. It’s a predictable outcome of poor design. These aren’t rare cases. They’re systemic. And they lead to harm-sometimes fatal.
The problem isn’t just names that sound alike, like hydralazine and hydroxyzine. It’s packaging that tricks the eye. Two different injectables in identical clear vials. Two oral suspensions with the same label layout. A diabetes drug and a blood pressure pill in nearly identical bottles. When you’re juggling 50 prescriptions an hour, your brain doesn’t read every word. It scans for patterns. And if two drugs look like twins, your brain picks the wrong one.
Start with Physical Separation
The simplest, cheapest, and most effective fix is physical separation. Keep look-alike drugs as far apart as possible in storage. This isn’t just a suggestion-it’s backed by data. A 2020 study from the University of Arizona found that separating visually similar medications reduced errors by 62%. That’s more than half the mistakes gone, just by rearranging shelves.
In a hospital pharmacy, this means putting insulin types in different drawers. In a retail setting, it means placing spironolactone and spiramycin on opposite ends of the shelf. You don’t need fancy equipment. Shelf dividers cost under $500. Use colored tape. Use labels. Use bins. The goal isn’t perfection-it’s forcing the pharmacist to pause. If two drugs are side by side, the brain skips the fine print. If they’re separated, the hand has to reach, the eyes have to focus, and the error rate drops.
One pharmacy in Boston cut wrong-insulin errors to zero after moving all insulin types into a locked, labeled section with only one product per drawer. No technology. No software. Just space and structure.
Use Tall Man Lettering Consistently
Tall Man Lettering (TML) isn’t new, but it’s still underused. It’s when you capitalize parts of a drug name to highlight differences: DOPamine vs. DoBUTamine, HYDROmorphone vs. HYDROchlorothiazide. The FDA and ISMP have been pushing this since the early 2000s. And it works.
A 2019 analysis of 15 hospitals showed TML reduced selection errors by 47%. But here’s the catch: it only works if everyone uses the same format. If Epic EHR shows HYDROmorphone but Cerner shows Hydromorphone, you’ve created a new problem. Pharmacists switching between systems get confused. A 2022 ASHP survey found 43% of pharmacists reported inconsistent TML across systems as a major source of confusion.
Fix this by standardizing. Work with your EHR vendor to ensure all drug names in your system use ISMP’s official TML format. If your system doesn’t support it, demand it. The FDA’s 2024 draft guidance now requires standardized TML for 25 high-risk drug pairs. You’re not just improving safety-you’re getting ahead of regulation.
Barcode Scanning Is Non-Negotiable
If you’re still dispensing without scanning barcodes, you’re gambling with patient safety. A 2021 AHRQ report found that full barcode scanning integration reduces medication administration errors by 86%. That’s not a suggestion. That’s a game-changer.
Here’s how it works: the pharmacist scans the drug, the patient’s wristband, and the prescription. The system checks: Is this the right drug? Right dose? Right patient? Right time? If not, it alerts you. No exceptions. No bypassing.
Yes, it costs money-$15,000 to $50,000 per pharmacy. But consider this: the average cost of a single medication error leading to hospitalization is $15,000 to $30,000. Mayo Clinic’s program saved $287,000 a year in avoided errors. That paid for the system in less than a year.
Don’t let staff bypass scanning. Make it part of your quality checklist. If someone skips a scan, it’s not a “busy day.” It’s a policy violation. Train staff on why it matters. Show them real cases. One nurse in New Jersey gave a patient the wrong heparin dose because she skipped the scan. The patient had a major bleed. He survived. But he didn’t walk again.
Combine Strategies for Maximum Protection
None of these tools work alone. You need layers. Like seatbelts, airbags, and crumple zones in a car. One layer fails? The next catches it.
A 2023 study in the American Journal of Health-System Pharmacy found that pharmacies using all three-physical separation, TML, and barcode scanning-achieved 94% error reduction. That’s nearly eliminating the problem.
Start with what you can do today. Separate your top 5 most confusing pairs. Apply TML to your EHR. Enforce scanning. Then add more. Over six months, build your safety net. Don’t wait for a tragedy to act. The Joint Commission requires you to address look-alike risks. You’re already being audited. Be ready.
Train Staff to Think Like Detectives
Technology helps. But people still make the final call. Train your team to question everything. When a new drug comes in, ask: Does this look like anything we already stock? Is the label layout similar? Is the bottle shape the same? Is the color scheme identical?
Erin Fox from the University of Utah Health says: “When new products arrive, do an extra review. Don’t assume the formulary team caught everything.” Drug shortages make this worse. When a popular brand is out, you might substitute a generic that looks totally different. But if you’re scrambling, you’re more likely to grab the wrong one.
Run monthly drills. Pick two look-alike drugs. Ask staff to find them on the shelf. Time them. See how long it takes. If it’s under 5 seconds, you’ve got a problem. The goal isn’t speed. It’s accuracy.
Watch for New Threats
The list of confusing drug pairs keeps growing. In January 2024, ISMP added 17 new pairs, including buprenorphine and butorphanol. Both are opioids. Both are used for pain. Both come in similar tablet forms. If you’re not checking the updated list quarterly, you’re falling behind.
Also watch for packaging changes. A drug manufacturer might switch to a new bottle design. It might look better. But if it now matches another drug’s look, you’re at risk. Stay in touch with your suppliers. Ask them: “Are you aware of any similar products on the market?”
What If You Can’t Afford Tech?
You don’t need a $50,000 system to make a difference. Most community pharmacies can’t afford full barcode integration. But you can still protect patients.
Use color-coded stickers. Put a red dot on high-risk pairs. Create a printed “Look-Alike Alert List” and post it near the counter. Use different shelving units. Put high-risk drugs in a separate bin. Train new hires to double-check every time they pick up a drug they’ve never dispensed before.
ISMP offers free tools to help. Download their Tool for Evaluating the Risk of Confusion Between Drug Names. Spend 8 hours reviewing your top 20 most common prescriptions. You’ll find 3-5 pairs you didn’t realize were dangerous. Fix those first.
It’s Not About Perfection. It’s About Prevention.
You won’t eliminate every error. But you can make them rare. The goal isn’t zero mistakes. It’s zero preventable mistakes. Look-alike packaging errors aren’t accidents. They’re design failures. And design can be fixed.
Start small. Separate two drugs today. Apply Tall Man Lettering tomorrow. Enforce scanning next week. Track your progress. Share wins with your team. When a wrong-drug error is avoided, celebrate it. Because someone’s life didn’t change because of luck. It changed because you did your job.
What are the most common look-alike drug pairs in pharmacies?
The most common pairs include hydralazine and hydroxyzine, DOPamine and DoBUTamine, HYDROmorphone and HYDROchlorothiazide, spironolactone and spiramycin, and buprenorphine and butorphanol. These pairs are frequently confused because they share similar spellings, packaging layouts, or bottle shapes. ISMP updates its list quarterly, adding new pairs based on reported errors.
Does Tall Man Lettering really reduce errors?
Yes, when used consistently. Studies show Tall Man Lettering reduces selection errors by up to 47%. But it only works if every system-EHR, labels, prescriptions-uses the same format. Inconsistent use actually increases confusion. The FDA now requires standardized TML for 25 high-risk drug pairs, making it a regulatory expectation, not just a best practice.
Can barcode scanning prevent all medication errors?
No, but it’s the most effective single tool. Barcode scanning reduces medication administration errors by 86%. However, it fails when staff bypass the scan, when barcodes are damaged, or when the system isn’t properly linked to the EHR. It works best when combined with physical separation and staff training. It’s a safety net, not a cure-all.
How often should pharmacies review look-alike risks?
Pharmacies should review look-alike risks quarterly, using ISMP’s updated List of Confused Drug Names. New drugs enter the market constantly, and packaging changes happen without warning. A review should include new formulary additions, substitutions during drug shortages, and any reported near-misses. Waiting for an error to happen is too late.
What’s the cheapest way to reduce look-alike packaging errors?
The cheapest and most effective method is physical separation. Using shelf dividers, colored tape, or separate bins to keep similar-looking drugs apart costs under $500 and can reduce errors by up to 62%. Pair this with printed alert lists and staff training. No technology required. Just intentional design and consistent habits.