The trouble with using color to help identify your medicine

 

Companies often use color on products to capture attention or differentiate items. For instance, bright colors may draw your attention to a specific word or detail on a label. Companies also use color to distinguish different products within their brand.

coke can
      Figure 1

Many people use color to quickly identify an item they are looking for. In fact, some people rely so heavily on color that when a change is made in the color of a specific product label, confusion is almost always certain. A good example of this phenomenon occurred when Coca-Cola changed its iconic red soda can (regular Coca-Cola) to silver last year to support a cause (figure 1). After a large amount of complaints about mistaking the can for Diet Coke (which has historically been packaged in a silver can) Coca-Cola changed the can back to red to avoid confusion.

As with all commonly marketed items, drug companies also use color to distinguish their products. And like other products, people may find themselves differentiating prescription medicines based on color alone (for instance, pills, tubes of ointments, eye and ear drops). Even prescription bottles have been marketed using colored rings to help distinguish one family member’s medicine from another’s (figure 2).

target color rings
Figure 2

But when it comes to medicine, overreliance on color can potentially lead to harm. For example, pharmacists have reported products being mixed upon shelves designated for another medicine. When investigating these types of errors, color of the label is a major factor in mistaking one product for another. Even when the name of the drug is completely different, mistakes can occur. Our organization frequently hears from healthcare providers all over the country who bring to our attention products that look too similar and have the potential for being mixed-up (See figure 3).  

Benztropine  OxybutyninUpsher Smith8-12

               Figure 3

When taking medicine at home, it is important to understand how color influences how we identify a product. In one case, a patient had been taking a prescription ear drop solution. When the prescription was refilled, the patient failed to notice that the pharmacy gave her the wrong drops. Instead of a solution, they had given her a suspension (figure 4). The patient relied only on the color (and look) of the package to identify her product.

neomycin

Figure 4

In another example, we heard from a woman who mistakenly took a sleeping pill instead of her thyroid medicine. The sleeping pill, zolpidem tartrate (generic for Ambien) had recently changed from white to blue (her pharmacy started using a different generic product). Her thyroid pill was also blue (figure 5). When traveling, the woman placed several pills in a pill container. Like every morning she took a blue pill, thinking it was her thyroid medicine. This time however, she grabbed the wrong blue pill, the new generic sleeping pill, and unexpectedly became sleepy.

ambien.synthroid mix-up1
                                         Figure 5

Regardless of your vision (regular vision, poor vision and those with color blindness), color should never be used as the primary means of identifying a product. Color should only be used to help locate and differentiate products. But for those with poor vision and color blindness, other methods of differentiating products can be used. For example, placing a rubber band around one product to differentiate it from another (i.e., rescue inhaler versus a maintence inhaler).

For all individuals, it is important to consider how color plays a role in how you identify your medicine. Doing so, can help you strategize before hand on ways to avoid a mistake where color may be involved. Familiarize yourself with other ways to identify your medicine, but most of all, the safest thing to do is take a brief “time-out” before taking any medicine. During this time, focus on the task and carefully read the product label before using.

 

Created on September 24, 2012

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