In the Fall of 2005, McNeil Consumer and Specialty Pharmaceuticals changed the packaging of its unit-dose TYLENOL (acetaminophen) 500 mg caplets for hospital use. The caplets, previously packaged in bright yellow packets, were switched to white packets to maximize accurate readability of the newly added bar code by scanning devices. Unfortunately, the new 500 mg packet looks virtually identical to the Tylenol 325 mg unit-dose packet (Figure 1). 

  Figure 1. “New” white 500 mg unit-dose packet and
  325 mg unit-dose packet (right) look-alike.

Pennsylvania healthcare facilities have reported multiple mixups involving these products to PA-PSRS. Practitioners have reported to ISMP and the manufacturer that the striking package similarities can lead to confusion and may result in excessive doses in facilities that do not use point-of-care bar coding.¹ As a result of all the reports received, the manufacturer will be returning to the familiar yellow packet reportedly in March 2006 that includes a bar code (Figure 2) and will continue to explore ways to improve scanning reliability while maintaining visually differentiated packaging.²

  Figure 2. Yellow Tylenol packet to return with barcode.

Notes

1. ISMP Medication Safety Alert! Acute Care Edition. Look-alike Tylenol packets. 17 November 2005.
2. ISMP Medication Safety Alert! Acute Care Edition. Your reports at work: Tylenol packaging returns to yellow. 26 January 2006.