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Risk of Medication Errors Due to Similar Drug Packaging

6th Oct 2020

Name and Constituency of Member of Parliament
Dr Tan Wu Meng
MP for Jurong GRC

Question No. 206

To ask the Minister for Health whether the risk of medication errors is assessed in the procurement of medications in public care institutions such as (i) lookalike packaging where different drugs have similar containers or packages and (ii) changes in drug concentration of syrups that may confuse patients and caregivers especially when medications are administered in the home.


1               The public health institutions (PHIs) and Agency for Logistics and Procurement Services (ALPS) are mindful of the risk of medication errors when medications that have similar appearing containers or packaging are dispensed or administered.  Look-alike medications may lead to different drugs or different doses of drugs being administered to patients, with potentially severe consequences.

2       Special care is taken when there are changes to the brands or strengths and these may occur when new drugs (or new generic drugs) become available, or when alternative drugs are needed due to manufacturing or supply-chain disruptions.

3       A multi-pronged approach is adopted to mitigate medication errors and this starts with the procurement process whereby similar appearing containers or packaging of medications are evaluated and suppliers are approached when improvements are required for better differentiation from other products.

4       PHIs educate pharmacy staff, doctors and nurses dealing with such medications on the changes in appearance or dosage, and how to mitigate the risk for errors.  Distinguishing symbols, colours or fonts are used when labelling the medications and the storage areas to highlight the differences in description of the medications.

5       When the medications are stored in the pharmacies and wards, different drugs with similar appearances are stored separately in different locations to reduce the risk of selecting the wrong drug.  In the wards, a process of counter-checks has been introduced to verify that the correct medication has been selected during the preparation of the medications and during administration.

6       Finally, when dispensing the medications to patients, PHIs affix “packaging or dose change” stickers in various languages on the dispensing packs.  Pharmacy staff also remind patients to pay attention to any changes to brands and/or strengths of products.

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