How to Prevent Look-Alike Packaging Confusion in the Pharmacy

Every year, thousands of patients in the U.S. receive the wrong medication-not because of a doctor’s mistake, but because two pills look too much alike. A bottle of spironolactone sits next to spiramycin. A box of DOPamine is stacked beside DoBUTamine. At a glance, they’re nearly identical. And in a busy pharmacy, where pharmacists are juggling dozens of prescriptions at once, that tiny difference can disappear. The result? A patient gets the wrong drug. Sometimes, it’s harmless. Other times, it’s deadly.

According to the Institute for Safe Medication Practices (ISMP), about 18% of all medication errors reported in U.S. pharmacies involve look-alike or sound-alike (LASA) drugs. That’s roughly 10,000 errors each year. And it’s not just about names. Packaging plays a huge role. The FDA estimates that 20% of errors come from confusing labels, colors, fonts, or bottle shapes. This isn’t a rare glitch. It’s a systemic problem-and it’s fixable.

Start with a Risk Assessment

You can’t fix what you don’t see. The first step is to find out which drugs in your pharmacy are most likely to be mixed up. ISMP provides a free Tool for Evaluating the Risk of Confusion Between Drug Names. It’s simple: list all your high-volume medications, then cross-check them against ISMP’s updated List of Confused Drug Names (January 2024 version). That list now includes 17 new pairs, like buprenorphine and butorphanol, which were added after multiple dispensing errors in 2023.

Don’t just rely on the list. Look at your own dispensing history. Have you ever pulled the wrong bottle and caught yourself? Did a nurse ever question a drug you dispensed? Those are red flags. Talk to your staff. Ask them: “What drugs do you second-guess?” You’ll often hear the same names over and over. That’s your priority list.

Use Tall Man Lettering Everywhere

Tall Man Lettering (TML) isn’t fancy tech. It’s just capitalizing the different parts of similar drug names to make them stand out. DOPamine vs. DoBUTamine. HYDROmorphone vs. HYDROxyzine. Simple. Effective. Proven.

A 2019 ISMP analysis found that TML reduces selection errors by 47%. But here’s the catch: it only works if it’s used consistently. A 2022 survey showed only 68% of hospitals use standardized TML formats. That’s a problem. If your EHR system shows HYDROmorphone but the pharmacy label says Hydromorphone, you’ve just created confusion instead of preventing it.

Make sure every screen in your pharmacy-your dispensing software, your inventory system, your label printer-uses the same TML format. Work with your EHR vendor. Demand it. The FDA’s 2024 draft guidance now mandates standardized TML for 25 high-risk pairs. You don’t want to be caught behind.

Separate Look-Alike Drugs Physically

Technology helps, but humans still pick the bottles. And humans make mistakes when things are close together.

A 2020 study from the University of Arizona found that physically separating look-alike drugs reduces errors by 62%. That’s not a suggestion. That’s a game-changer.

You don’t need a new storage room. Use shelf dividers. Buy plastic bins. Put red tape on the floor. Put insulin glargine and insulin lispro in completely different drawers. Keep heparin and saline on opposite sides of the counter. One pharmacy in Mayo Clinic did this and eliminated 100% of potential heparin-saline mix-ups in 12 months.

High-volume pharmacies say space is tight. That’s true. But even a few inches of distance makes a difference. One retail pharmacy in Bristol used $300 worth of colored bins and dividers to separate spironolactone, spiramycin, and sertraline. Within six months, wrong-drug claims dropped by 75%.

Implement Barcode Scanning-But Don’t Rely on It Alone

Barcode scanning is the most powerful tool in the toolbox. When done right, it cuts medication administration errors by 86%, according to the Agency for Healthcare Research and Quality (AHRQ).

But here’s what most pharmacies miss: scanning only works if staff actually scan. A 2021 study from UCSF found that 5-12% of staff bypass the scanner during busy hours. Why? Because it slows them down. So they swipe the barcode anyway-without scanning.

Don’t just install scanners. Change the culture. Make scanning non-negotiable. Add it to your daily checklist. Reward teams that hit 100% compliance. And never let someone override the system without a second verification. The cost? $15,000 to $50,000 per pharmacy. But Mayo Clinic’s 2023 analysis showed their program saved $287,000 a year in prevented errors. That’s a 6x return.

Train Staff to Think Like Detectives

Technology helps. But the last line of defense is always the person holding the bottle.

Train your staff to pause before dispensing. Ask: “Does this look right?” “Is this the same as last time?” “What’s different?”

One pharmacy manager in Ohio started a simple ritual: every time a new drug arrives, the pharmacist does a “look-alike check.” They compare the new package to everything already on the shelf. Is the font similar? Is the color close? Is the shape the same? In one case, they caught a new generic version of metoprolol that used the exact same bottle as metformin. They flagged it before a single pill was dispensed.

Use real examples in training. Show photos of past near-misses. Let staff talk about their own mistakes. Shame doesn’t help. Learning does.

Label with Clarity, Not Just Compliance

Just because a label meets FDA minimums doesn’t mean it’s safe. Many labels are cluttered, tiny, or use similar fonts and colors.

Go beyond the law. Add a bright yellow “LOOK-ALIKE” sticker to high-risk drugs. Use bold, sans-serif fonts. Increase the font size. Avoid using the same color for different drug classes. For example, don’t put all blood pressure meds in blue bottles. Use red for insulin, green for anticoagulants, orange for sedatives.

One community pharmacy in Bristol started printing custom labels with a warning: “CONFUSED WITH [DRUG NAME]. DOUBLE CHECK.” They didn’t need new software. Just a printer and a bit of courage. Their error rate dropped by 60% in four months.

Combine Strategies for Maximum Safety

No single fix works alone. The most effective pharmacies use all three: physical separation, TML, and barcode scanning.

A 2023 study in the American Journal of Health-System Pharmacy found that combining these three strategies reduced errors by 94%. That’s nearly complete prevention.

Start small. Pick one high-risk pair-say, clonazepam and clonidine. Separate them on the shelf. Add Tall Man Lettering to your system. Then require barcode scanning for both. Track your progress for 30 days. If errors drop, do it again with another pair.

It’s not about perfection. It’s about layers. One layer might catch a misread name. Another might catch a wrong bottle. A third might catch the person who skipped the scan. Together, they create a safety net.

What Happens If You Do Nothing?

Every year, about 7,000 people in the U.S. die from medication errors. Many of those involve look-alike packaging. The Joint Commission requires pharmacies to address this. The FDA is tightening rules. Insurance companies are starting to penalize hospitals for preventable errors.

But beyond compliance, think about the human cost. A patient gets the wrong drug. They have a seizure. They go to the ER. Their family blames the pharmacy. The pharmacist loses sleep. The trust is broken.

You don’t need a big budget. You don’t need new software. You need attention. You need discipline. You need to treat every bottle like it could be someone’s life.

The tools are there. The data is clear. The mistakes have been made before-and they’ve been fixed. It’s not about technology. It’s about choosing to do better.