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Rev Assoc Med Bras. 2012 Jan-Feb;58(1):95-103.

[Analysis of similar drug labeling: potential medication errors].

[Article in Portuguese]

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  • 1 Farmácia Hospitalar, Hospital Universitário Walter Cantídio da Universidade Federal do Ceará, Aluna do Curso de Doutorado em Farmacologia, Universidade Federal do Ceará, Fortaleza, CE, Brasil. .



This study aimed to examine drug packaging and labeling, identifying similarities among them that may lead to medication errors, which may occur by unintentional substitution, in different sectors of the pharmacy of a university hospital in northeastern Brazil.


Cross-sectional observational study, which included 300 pharmaceutical presentations (150 pairs) that were photographed from May to December 2010. Concordance analysis of data related to the pictures of possibly similar packaging and labels was validated using the Kappa index.


Of all drugs evaluated (n = 150), about 43% of "possibly similar drugs" were in the central pharmacy (n = 65) and were related to small-volume parenteral solutions. The strength of interobserver agreement in the category "very similar to each other" was considered "satisfactory" (Kappa = 0584) in 90.66% of the drugs evaluated (n = 136). The overall Kappa analysis of the study was 0.488. Variables with statistical significance were: "same color label or packaging", with the respective percentages for both primary and secondary packaging (52%-44%), p = 0.028; the variable "same color of drug presentation" obtained similar values and statistical significance to the previous variable; for the variable "same arrangement of words", the values found for both packages were close to 50%, p = 0.001; and for the variable "same color of the words", the percentages were: (50.7% - 44%) (p = 0.008).


Our results indicate similarities related to the labeling of drugs with potential for errors, especially in dispensing, storage, and administration if preventive measures are not adopted.

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