Drug treatment errors are common, with 20% of all medical negligence treatment claims arising from incorrect use of prescription drugs [1], mistakes being not only costly to individuals but also having a financial impact on the National Health Service in the United Kingdom. These errors can occur at several stages, including prescribing, transcription, dispensing and administration, effects varying in severity from minimal, and thereby unrecognized, to fatal [2, 3]. We report a case in which an incorrect medication was dispensed but was labelled as the prescribed drug. A 37-year-old female patient underwent a mitomycin C-augmented trabeculectomy for advanced glaucoma. The procedure was uneventful and the patient was discharged on topical medications of prednisolone acetate 1% (Prednefrin Forte, Allergan, Bucks, UK) six times a day and chloramphenicol 0.5% four times a day, to be tapered over the next 3 postoperative months. At her 2-week follow-up it was noticed that she had actually been dispensed a bottle of fluorometholone 0.1% (FML, Allergan, Bucks, UK), which was in its correct packaging but mislabelled as Prednefrin Forte by the pharmacist. The patient had assumed that it was Prednefrin Forte. As this error was discovered early, the patient did not suffer from any adverse outcome. Previous studies have estimated the accuracy of dispensing prescriptions to be around 98.3% and 6.5% of the errors were judged to be clinically significant [4]. This is a considerable number bearing in mind it has been calculated that even in a 600-bed teaching hospital with a 99.9% error-free drug ordering, dispensing and administration, 4000 drug errors would occur each year [5]. Computer-based prescribing systems minimize the risk of mistakes resulting from illegible prescriptions. However, they do not address actual dispensing errors. Robotic dispensing on the other hand can eliminate human error when selecting packs, as the computer system both stores and picks the medications using specific bar codes on the packaging rather than depending purely on recognition [6]. However, as robotic dispensing systems are currently the exception as opposed to the rule in UK pharmacies, making medicines of similar types or strengths easily distinguishable is at present still an important factor. Problems occurring from similar packaging have already been described with different strengths of oral medication, such as carbamazepine, with potentially devastating effects [7]. Not surprisingly many patients requiring ocular medications have poor sight, resulting in numerous mishaps regarding eye drop instillation, examples including superglue and stoma deodorant [8, 9]. This has generated discussion on packaging, which particularly emphasized that only ophthalmic medications should be dispensed in dropper bottles [10]. In this case, the pharmacist had mistaken the bottle of fluorometholone, a weak steroid, for Prednefrin Forte, with consequent labelling and dispensing error. If this error had remained undiscovered, early surgical failure would be likely to have resulted due to inadequate anti-inflammatory activity. The case described above reinforces this point as the packaging of Prednefrin Forte and fluorometholone are remarkably alike. The boxes and bottles are identical in size, shape and colour. In addition, the text and colours chosen are virtually indistinguishable at first glance (Figure 1). Medications should not only be double checked at the time of dispensing but also by the prescribing physician or surgeon. When patients attend ophthalmology outpatients, it is essential that they are advised to bring all topical medications so that they can be checked. This is of particular importance in postoperative patients. Although the patient did not experience any adverse effects in this case, such errors are a cause for concern given the potentially serious consequences. Figure 1 Packaging of FML and Pred Forte