Users Online: 1530 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 

RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to [email protected] preferably by 30th June 2019.


Table of Contents
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 133-134

“Look alike” packaging: Do we need a wake-up call?

Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Nandini M Dave
C 303, Presidential Towers, LBS Marg, Ghatkopar West, Mumbai - 400 086, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

Rights and PermissionsRights and Permissions

How to cite this article:
Dave NM. “Look alike” packaging: Do we need a wake-up call?. J Anaesthesiol Clin Pharmacol 2018;34:133-4

How to cite this URL:
Dave NM. “Look alike” packaging: Do we need a wake-up call?. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2021 May 13];34:133-4. Available from:

This is to report the striking similarity of 20% w/v mannitol injection and 25% w/v dextrose injection 100 ml pints that were supplied to the tertiary care University teaching hospital. We follow a zero prescription policy, whereby drugs and intravenous fluids, besides other consumables needed for procedures and treatment are available on schedule. As per the government procurement policy, a company whose product matches the specifications and is lowest on the price list is awarded the rate contract for the supply. While this process is established to ensure fair play, it sometimes results in suboptimal quality of supplied goods.

In this case, both fluids were manufactured by the same company. An earlier batch had some difference in the color shade [Figure 1]. The subsequent batches looked exactly similar [Figure 2]. Although no untoward incident occurred, this was brought to the notice of the purchase department and the manufacturing unit.
Figure 1: Look alike labeling: 25% dextrose and 20% mannitol, slight difference in color

Click here to view
Figure 2: Look alike labeling: 25% dextrose and 20% mannitol, similar color and shade

Click here to view

Much has been written in the literature about the perils of look alike, sound alike drugs.[1],[2] Equally important is the packaging and labeling of drugs. Mangar et al. write that reporting every look-alike is no longer novel; similarities between labels are a fact of life.[3] I however, beg to differ. I think it is imperative we continue to report such potentially dangerous practices. This will ensure that pharmaceutical companies are forced to revisit their processes.

To guarantee that our patients' safety is not jeopardized, meticulous packaging specifications need to be put in place.[4] In addition, the regulatory authorities should periodically scrutinize the quality and packaging of medications and ensure that the stringent guidelines are being adhered to. Policy makers should be sensitized to the issue that it should be a quality product, and not necessarily the cheapest product that should reach the patient. As end users, we should be ever vigilant and continue to report such incidents that have potential to cause harm. Ensuring patient safety should be a consistent and continuous process, with no room for compromises or complacency.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kothari D, Gupta S, Mehrotra A. Look alike drugs ‒ A worrying issue. Indian J Anaesth 2009;53:708-9.  Back to cited text no. 1
Arora V, Bajwa SJ, Kaur J. Look alike drug labels: A worrying issue. Indian J Anaesth 2011;55:428.  Back to cited text no. 2
Mangar D, Miguel R, Villarreal JR. Reporting every look-alike is no longer novel: Similarities between labels are a fact of life. J Clin Anesth 1992;4:347-8.  Back to cited text no. 3
McCoy LK. Look-alike, sound-alike drugs review: Include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf 2005;31:47-53.  Back to cited text no. 4


  [Figure 1], [Figure 2]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Article Figures

 Article Access Statistics
    PDF Downloaded136    
    Comments [Add]    

Recommend this journal