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Reporting a Medication Error

Desiccant Mistaken as Medicine Tablet

Published May 23, 2024

Figure 1. The blister card included a desiccant that was labeled, “DESICCANT DO NOT EAT.”

Desiccants are substances that are added to some packages to preserve the product, but they should not be eaten. Medicines are sometimes packaged with a desiccant to help absorb moisture and make sure their effectiveness does not decrease over time. If a desiccant is packaged with the medicine, the package label may include a warning such as, “DESICCANT DO NOT EAT” (Figure 1). But people may not see the warning and take the desiccant by mistake.

Figure 2. Desiccant (circled in red) is similar in size and color to amoxicillin tablets (circled in blue).

In 2022, we wrote about desiccants being mistaken as medicine when they were packaged in blister cards (Figure 1). But desiccants are also packaged with prescription and over-the-counter (OTC) medicines that come in bottles. We recently received a report about a desiccant being mistaken as an antibiotic tablet that was included in the medicine bottle.

An older man with poor eyesight had decreased feeling in one of his hands after having a stroke. He was given a prescription for an antibiotic, amoxicillin, to treat an infection. When it was time to take a dose of the medicine, he accidentally swallowed the desiccant that was included in the package and choked. Thankfully, his caretakers were close by and able to help him so that he was not harmed.

The amoxicillin was a white oval tablet. The desiccant was about the same size and color (white) as the amoxicillin tablets (Figure 2). The package label (Figure 3) did not include a warning that the bottle contained a desiccant. Since the man was not able to clearly see or feel the difference between the tablet and the desiccant, it is easy to see how the error happened. Although drug manufacturers state that the desiccants they use are not harmful (toxic) to a person, people may choke on them.

Figure 3. The package label does not state that a desiccant is included with the medicine.

Here's what you can do: When picking up a prescription from the pharmacy, ask to talk to the pharmacist. Open the bag of medicine in front of the pharmacist to make sure it is correct. Look for any warnings on the label and make sure you understand what the warning means. Ask the pharmacist if any of the information is confusing to you. Ask if the medicine bottle contains a desiccant. When you go to take your medicine, make sure you have enough light so you can read the label and instructions. If you know the medicine bottle contains a desiccant, look closely at the medicine before you take it. If you accidentally swallow a desiccant, call your doctor or healthcare provider.

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