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Reporting a Medication Error

Using Color to Identify Your Medicine Can Result in an Error

Figure 1.Colored rings applied to a medicine bottle to help family members identify their medicine.

Companies often use color on their logos and products to get your attention or to show product differences. For example, bright colors may draw your attention to a specific word or detail on a label. Some medical and pharmaceutical companies also use color to help identify their products. Color may help people tell the difference between similarly shaped items that each person in the family uses (e.g., toothbrushes).

A few years ago, colored rings (Figure 1) were added to some prescription bottles to help identify which family member’s medicine was in which bottle. For example, the mother’s medicine had a green ring, the father’s medicine had a red ring, and the daughter’s medicine had a purple ring. Unfortunately, using color can be problematic, especially for those who are colorblind. This method of using color-coded rings was discontinued in 2016.

Figure 2.Some medical organizations support the use of color to indicate different types of medicines. For example, this list shows the color codes used for eye(ocular) medicines.

Healthcare providers, including pharmacists, may also rely on color to identify a medicine. For example, eye drops have been assigned specific colors so they can be easily identified by healthcare providers when used. The American Academy of Ophthalmology still promotes the use of a color-coding system on the caps and labels of eye medicines (Figure 2).

However, relying on color to identify medicines can lead to an error and harm. For example, product mix-ups have occurred when medicines that have similarly colored labels are next to each other on a shelf. It is easy to accidentally pick the wrong medicine if you are looking for a certain color on the label. Even when the drug name is completely different, mistakes can occur (Figure 3).

Figure 3.These containers of medicine have similar label colors and can be easily confused if stored next to each other.

The same problem can happen when taking medicine at home. In one case, a woman had been taking a prescription ear drop solution. When the prescription was refilled, this woman failed to notice that the pharmacy gave her the wrong drops. Instead of a clear solution, she received a suspension (Figure 4). The pharmacy dispensed the ear drops in the package provided by the company. The woman had relied only on the package’s color (and look) to identify her ear drops. Since both forms of the ear drops were made by the same company, it was difficult to tell them apart.

 Figure 4. These ear drops are the same medicine but different formulations. The one on the left is a clear solution, while the one on the right is a suspension.

Sometimes people rely on the color of the actual medicine to know which one to take. In these cases, the label on the medicine may not be read to make sure it is the correct medicine or dose prior to taking it. For example, a pharmacist was checking a medicine container and found two brown, round tablets that had very similar tablet codes, “I 2” and “I-2” (Figure 5). The pharmacist did a search of the tablet codes to see if these medicines were the same or different. It turns out, the medicine with the “I 2” code was amitriptyline hydrochloride 25 mg, an antidepressant. The medicine marked “I-2” was ibuprofen 200 mg. Fortunately, the pharmacist noticed the slight difference in the codes and prevented an error.

Figure 5. The tablets shown look very similar based on their size, shape, color, and code. However, the one on the left is amitriptyline hydrochloride and the one on the right is ibuprofen.

Here’s what you can do: Color should never be used as the primary means of identifying your medicine(s). Color should only be used to help locate and differentiate products, especially when taking multiple medicines. For people with poor vision or who are colorblind, other methods of telling medicines apart can be used. For example, placing a rubber band around one product’s container will make it feel different from the other product.

It is important to understand that it is not always safe to use color to identify your medicine(s). This will help you avoid making a mistake when taking medicines. Ask your pharmacist for other ways to help you identify your medicine. Give yourself enough time to take your medicines. Always take your time to read the label before taking any medicine and ask your pharmacist or doctor if you have concerns about your medicines.

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