Guest Column | December 7, 2023

Drug Labeling: 3 Pitfalls To Avoid And 8 Best Practices To Follow

By Mary Anne Roberto, Always Home Connected

Healthcare, medicine and drug types, pharmaceutical packaging-GettyImages-673531980

Drug labeling errors can have serious consequences for patients and healthcare providers. While manufacturers play a crucial role in ensuring the accuracy and clarity of medication labels, errors can still occur during the packaging, printing, or labeling process. These errors can range from ambiguous or unclear dosage instructions or warnings to incorrect or incomplete information on labels. In this article, we will explore three common labeling pitfalls and the strategies that drug manufacturers can employ to prevent them and enhance patient safety.

Pitfall #1: Equipment Errors

One common source of medication mislabeling is equipment errors that occur during the printing or labeling process. Specialized printers and inks are designed to withstand the rigors of the process. However, even with the best printing equipment, errors can still occur. For example, a printer may malfunction and print incorrect information on the labels, or the ink may smudge, making the text illegible. Additional errors can include typographical mistakes, incorrect representation of dosage information, or incomplete warnings.

While these errors may seem minor, they can have severe consequences for patients and healthcare providers alike.

Pitfall #2: Human Errors

For instance, a worker may accidentally place the wrong label on a medication bottle, leading to confusion and potential harm to the patient.

A contributing factor to this scenario is that the packaging, printing, and labeling processes are often carried out in fast-paced environments, where workers may be under pressure to meet production quotas. This can increase the likelihood of errors occurring. Fatigue, distractions, and lack of attention to detail can all contribute to mistakes.

Pitfall #3: Your Dosage Instructions or Warnings Are Unclear

Another key area where manufacturers can contribute to medication mislabeling is the lack of clarity in dosage instructions or warnings.

Imagine a scenario where a patient is prescribed a new medication for a chronic condition. They carefully read the label, hoping to find clear instructions on how to take the medication. Unfortunately, they are met with vague language that leaves them confused and uncertain. This lack of clarity can be a major source of frustration and anxiety for patients, as they may not know how to properly administer the medication or what potential risks they should be aware of. This can have serious consequences for patients, as it may lead to incorrect dosing or failure to follow necessary precautions.

Manufacturers play a crucial role in ensuring that medication labels are easy to understand and devoid of any ambiguity.

8 Best Practices To Prevent Medication Labeling Errors

  1. Enact Stringent Quality Control Measures: This includes conducting regular inspections of the packaging materials to ensure they meet the required standards. Additionally, thorough checks should be performed during the printing process to verify the accuracy of the information being printed on the labels. Lastly, a comprehensive labeling system should be in place to ensure that the right labels are applied to the correct medication containers.
  1. Ensure Your Standard Operating Procedures Are Properly Descriptive: One of the key strategies for drug manufacturers to prevent medication mislabeling is the development of and adherence to strict SOPs¹ related to labeling and packaging. By following these SOPs rigorously, you can minimize the chances of errors and ensure consistency in labeling practices.
  1. Document And Verify Processes At Each Stage Of Production: Implement robust documentation and verification processes at each stage of production. This includes thorough record-keeping of labeling activities, regular quality checks, and independent verification of labeling accuracy. By maintaining meticulous documentation and performing regular audits, manufacturers can identify any potential issues early on and take corrective measures promptly.
  1. Integrate Advanced Technology: Advancements in technology have significantly contributed to enhancing the accuracy and efficiency of drug labeling and packaging processes. For instance, the use of automated labeling machines can reduce the likelihood of human errors. Additionally, barcoding and scanning technology can ensure accurate and efficient tracking of medications throughout the supply chain.
  1. Ensure Regulatory Compliance: Have a clear understanding of and adhere to the guidelines set forth by regulatory bodies such as the FDA². Periodic internal audits should also be conducted to evaluate and ensure ongoing compliance with regulatory guidelines.
  1. Create Risk Management And Contingency Plans: No matter how robust the labeling processes are, there is always a potential risk of mislabeling incidents³. Develop comprehensive risk management strategies to mitigate these risks and have well-defined contingency plans in place. These plans should include protocols for immediate recalls, as well as clear procedures for corrective actions to minimize harm to patients and mitigate legal liabilities.
  1. Develop Risk Assessment Strategies To Identify Vulnerabilities: To prevent medication mislabeling, manufacturers should proactively identify vulnerabilities in their labeling processes. Implementing risk assessment strategies can help identify potential weak points and areas susceptible to errors. This includes evaluating the impact of labeling errors on patient safety, analyzing the root causes of previous incidents, and implementing preventive measures to address identified risks.
  1. Special Spotlight: Rigorous Product Testing With Focus Groups: This strategy will help you directly address pitfall #3. It requires a comprehensive approach that involves rigorous product testing and the involvement of various stakeholders. By conducting focus groups with patients, healthcare professionals, and regulatory experts, manufacturers can gain valuable insights into how their instructions and warnings are perceived. During these focus groups, participants can provide feedback on the clarity of the instructions, identify any potential areas of confusion, and suggest improvements. This collaborative approach allows manufacturers to fine-tune their labeling to ensure that it meets the needs and expectations of the end users. It also helps in identifying any language that may be open to misinterpretation or may not adequately convey the necessary information.

Comprehensive product testing is essential to ensure that the dosage instructions and warnings are effective in real-world scenarios. This involves conducting usability studies where participants are observed while interacting with the medication label. By observing how users interpret and follow the instructions, manufacturers can identify any potential pitfalls or areas where the label may be misinterpreted.

Manufacturers must also keep in mind the diverse range of patients who may be using their medication. Different individuals may have varying levels of health literacy or language proficiency. Also, complex medical terminology or poorly organized information can make it challenging for both patients and healthcare providers to understand the medication's proper use and potential risks. It is crucial that the instructions and warnings are designed to cater to a wide audience, using language that is clear, concise, and easily understandable by all.


By implementing the above measures, manufacturers can significantly reduce the occurrence of errors during the labeling process. This, in turn, helps to safeguard patient safety and maintain the integrity of the healthcare system as a whole. It is imperative for manufacturers to prioritize the development and implementation of comprehensive risk management and contingency plans to handle mislabeling incidents effectively.


  1. NUCats - Northwestern University titled Standard Operating Procedures (SOPs)
  2. U.S. Food and Drug Administration July 7th, 2023 titled FDA’s Labeling Resources for Human Prescription Drugs | FDA
  3. National Library of Medicine March, 2017 titled A Mislabeling Event With Batched Drugs: The Unintended Consequences Of Practice Changes - PMC

About The Author:

Mary Anne Roberto is the co-founder of Always Home Connected, a dedicated CNA, and a PAC Certified Independent Consultant specializing in dementia care.