title: Case report of a medication error: In the eye of the beholder.
abstract: BACKGROUND
  The World Health Organisation recognizes confusing drug names as one of the most common causes of medication errors. Other factors include spelling, phonetic, or packaging similarities.
  
  
  METHODS
  We presented a case report of an inadvertent administration of a non-ocular pharmaceutical product (Novasone lotion) into the eye of an octogenarian individual, and briefly reviewed the relevant literature.
  
  
  CONCLUSIONS
  We discussed prevention strategies to avoid similar ophthalmic medication errors.
authors.affiliation: Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Naunton
authors.forename: Kowsar
authors.initials: K
authors.lastname: Nor
authors.forename: Andrew
authors.initials: A
authors.lastname: Bartholomaeus
authors.forename: Jackson
authors.initials: J
authors.lastname: Thomas
authors.forename: Sam
authors.initials: S
authors.lastname: Kosari
mesh_terms: D000369:Aged, 80 and over; D003879:Dermatologic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D004348:Drug Labeling; D005131:Eye Injuries / Q000139:chemically induced* / Q000628:therapy; D005260:Female; D006801:Humans; D008508:Medication Errors; D000068656:Mometasone Furoate / Q000008:administration & dosage / Q000009:adverse effects*; D009735:Nursing Homes
chemical_list: D003879:Dermatologic Agents; D000068656:Mometasone Furoate