Transparent error.

This article reports a case of about-to-happen medication error because of the identical packaging of different medicines. According to the reported case, a nurse in a longterm care facility who was about to administer eyedrops, named HypoTears PF containing polyvinyl alcohol/ polyethylene glycol 400, to a resident noticed that the clear, single-dose container she had picked up from the resident's medication drawer contained albuterol inhalation solution. The plastic container, very similar to that of HypoTears PF, had been mistakenly placed in the drawer. It is here suggested that, to prevent mix-ups like this, one has to make sure that products in similar packages are stored separately. If the product name on single-dose containers is not clearly visible, one has to ask the pharmacy to store the containers in the original outer packaging, if possible.