[Medication error due to drug packaging: a case report]

Nowadays, occurrence of medication errors is a public health concern at hospital. Drug packaging represent one of the important causes of medication errors. The authors report a medication error associated with an erroneous interpretation of drug packaging information. This error was detected during the pharmaceutical review of the medical prescription. The nursing staff in charge of drug administering must thus be particularly aware of this risk. The potential clinical significance of this type of medication error may be important.