Case report of a medication error: In the eye of the beholder

Introduction: 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. Case presentation: 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. Discussion: We discussed prevention strategies to avoid similar ophthalmic medication errors