Look-Alike Packaging: How Similar Drug Labels Cause Mistakes and How to Stay Safe

When two medicines look almost identical—same color, same shape, same label layout—it’s not a design choice. It’s a look-alike packaging, a dangerous similarity in drug appearance that leads to medication errors. Also known as similar drug packaging, it’s one of the top causes of preventable harm in hospitals and homes. You might think pharmacists and doctors catch these mix-ups, but they don’t always. A 2022 study from the U.S. Pharmacopeia found that over 1 in 5 medication errors linked to packaging involved drugs that looked nearly the same. And it’s not just about the bottle. It’s the font size, the logo placement, the color of the cap—tiny details that add up to life-threatening mistakes.

Think about hydroxyzine, an antihistamine used for anxiety and itching and hydralazine, a blood pressure drug. Both start with "hyd-", both come in white capsules, both are dispensed in similar bottles. One calms your nerves. The other lowers your blood pressure. Give the wrong one to someone and you could cause a stroke or a dangerous drop in heart rate. This isn’t rare. The FDA tracks over 1,000 cases each year where patients got the wrong drug because the labels were too close. And it’s not just brand names. Even generics can look identical if made by the same manufacturer for different brands.

People with low vision, a condition that makes reading small print difficult are especially at risk. If you can’t tell the difference between a blue pill and a white one, or if the text on the label is too faded, you’re relying on memory—or luck. That’s why medication safety, the practice of preventing errors in drug use isn’t just about prescriptions. It’s about how drugs are made, labeled, and handed out. Some pharmacies now use color-coded caps or tactile markers, but most don’t. You can’t wait for the system to fix itself.

So what can you do? Start by asking your pharmacist: "Are there other pills that look like this one?" Keep a photo of each pill in your phone. Use a pill organizer with clear labels. Never rely on the shape or color alone. If a pill looks different from last time, ask before you take it. Look-alike packaging is a systemic problem, but every mistake it causes is personal. The drugs below—like the ones in our posts on medication safety, prescription labeling, and medication errors—show how real this is. You’ll find real stories, real fixes, and real steps to protect yourself or someone you care about. This isn’t theoretical. It’s happening right now, in kitchens, nursing homes, and ERs. And you can stop it before it happens to you.