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. 2022 Apr;70(4):1159-1162.
doi: 10.4103/ijo.IJO_2328_21.

Joint pain liniments and gum lotion in the eye - A consecutive case series of mistaken identity

Anju Ajitha Jayaprakash  1 , P R Aswin  1 , S R Rathinam  2
Affiliations

Joint pain liniments and gum lotion in the eye - A consecutive case series of mistaken identity

Anju Ajitha Jayaprakash et al. Indian J Ophthalmol. 2022 Apr.

Abstract

Purpose: Patient safety errors can arise due to similarity in packaging of medications. We aimed to describe the clinical features of patients presenting with accidental application of joint pain liniments and gum lotion in the eye due to confusion arising from similarity in packaging.

Methods: This was a retrospective case series with eight consecutive patients presenting from December 2020 to August 2021 with history of accidental application of joint pain liniments or gum lotion in the eye instead of eye drops. All patients underwent visual acuity assessment and slit-lamp examination with fluorescein staining of the cornea to look for corneal involvement and was reassessed till complete resolution.

Results: Of the eight patients, three were males and five were females. Seven had accidentally applied joint pain liniment, while one had applied gum lotion into the eye. Five of them had corneal involvement ranging from punctate erosions to near-total epithelial defects. Two patients needed referral to a tertiary center and hospital admission. Treatment duration ranged from 2 days to 1 month. Two patients were lost to follow-up.

Conclusion: This study highlights patient safety errors arising from confusion of medication due to similar labeling and packaging of different drugs. While there was no permanent morbidity, such confusions lead to needless discomfort and waste of time, money, and effort for the patient as well as the health-care system.

Keywords: Look Alike-Sound Alike (LASA); medication error; patient safety.

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Conflict of interest statement

None

Figures

Figure 1
Figure 1
Packaging of joint pain liniments: (a) Fenlong MR (b)Ediment and (c) Myofenac Pro
Figure 2
Figure 2
Anterior segment photograph showing fluorescein stained large epithelial defect with conjunctival congestion under diffuse illumination and cobalt blue filter
Figure 3
Figure 3
Anterior segment photograph showing fluorescein stained epithelial defect at presentation (a), under cobalt-blue filter (b) and improvement after 3 days of treatment and application of BCL (c and d). BCL = bandage contact lens
Figure 4
Figure 4
Image showing similarity of packaging of Zingisol gum astringent compared with Azarga eye drops
Figure 5
Figure 5
Image showing similarity of packaging of joint pain liniment Fenlong MR and 10 ml Festive Dee eye drops
See this image and copyright information in PMC

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References

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