Package Color Coding Called into Question

The Institute for Safe Medication Practices (ISMP) and the American Association of Eye and Ear Centers of Excellence (AAEECE) are urging the end of a voluntary package color coding system for eye and ear products. According to AAEECE, color coding of certain ophthalmic medications may relate to medication errors.

For instance, AAEECE recounts errors such as the dispensing of "a 5 mL Tobramycin and Dexamethasone ophthalmic suspension instead of a 5 mL 1% Prednisolone Acetate ophthalmic suspension" and the administration of "glaucoma eye drops instead of anti-inflammatory eye drops" because a patient reports that “the letters and bottles all look the same to me.”

AAEECE claims that such look-alike sound-alike (LASA) medication errors "occur on a daily basis here in the United States and worldwide in hospitals, pharmacies, physician offices, ambulatory clinics or in a patient’s home." A voluntary color-coding system for identifying eye drops by therapeutic class that meant to reduce errors may unintentionally relate to them.

AAEECE shares ISMP's statement on its Web site: “the downside of color coding products in this manner is that items within each class become more difficult to differentiate. Also when similar corporate logos, fonts, package sizes, and color combinations are factored in, what may work well in an office setting or in a patient’s home does not necessarily work well in pharmacies or on the nursing units.”

The groups hope to convince FDA and manufacturers to consider abandoning the use of color coding. Click here for more details and examples of look-alike medications as well as to sign an e-petition to end such color coding.