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Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors

FinalCenter for Drug Evaluation and Research05/18/2022

Description

The purpose of this guidance is to help human prescription drug and biological product sponsors, application holders, and applicants minimize medication errors associated with their products. This guidance focuses on safety aspects of the application holder’s container label and carton labeling design. It provides a set of principles and recommendations for ensuring that critical elements of a product’s container label and carton labeling are designed to promote safe dispensing, administration, and use of the product.

Scope & Applicability

Product Classes

10
Human Prescription Drug

guidance applies to drugs regulated under section 505

Prodrugs

Products that are converted to the active moiety after administration.

Pharmacy Bulk Package

The container closure system of a sterile preparation for parenteral use that contains many single doses

Transdermal and topical systems

Transdermal and topical systems should include an identifying label on the backing membrane

Injectable drugs

For injectable drugs for parenteral administration, the inclusion of the package type term is important

Product Samples

Must bear labels denoting status as a drug sample.

Pharmacy Bulk Packages

Sterile preparations for dispensing single doses to many patients in a pharmacy admixture program.

Large-Volume Injections

Parenteral drug products intended for intravenous infusion; Container labels should be devoid of clutter to mitigate confusion and errors.

Controlled Substance

Drugs subject to the Controlled Substances Act requiring schedule display

Neuromuscular Blocking Agents

requires specific cautionary statements and red bold font

Stakeholders

3
Sponsor

Entity responsible for submitting applications under section 524B

Application Holder

Entity responsible for the approved NDA or ANDA; entity responsible for risk assessment

sponsors

Target audience for recommendations on assessment of overall survival

Regulatory Context

Attributes

10
Tall Man Lettering

Special consideration for product names to minimize errors

Readability

Content recommendation for patient labeling

Child-resistant

indicating the package is not child-resistant

Package type

inclusion of the package type term on container labels and carton labeling

Osmolarity statement

Recommended against on large-volume injection labels unless required by USP.

Lot number

Required information on unit dose blister cell labels

Beyond-Use Date

BUD is restricted to the last time point at which the data remained within specifications

Net Quantity of Contents

Required element on the principal display panel

Finished dosage form

established name for drug products should be displayed with the finished dosage form

Corporate trade dress

Visual branding used to distinguish products which must not compromise legibility.

Identified Hazards

Hazards

7
Look-Alike Container Labels

Design risk that can lead to medication errors

Bloodborne pathogens

reuse of insulin pens on multiple patients can result in exposure to bloodborne pathogens

Respiratory Arrest

risk associated with NMBAs

Underdosing

wrong strength can be selected or the wrong dose administered

Overdosing

wrong strength can be selected or the wrong dose administered

Medication error

Risks resulting from misinterpreted abbreviations, poor legibility, or look-alike packaging.

Medication Errors

safety considerations to minimize medication errors; minimize medication errors through label design

Related CFR Sections (16)

Related Warning Letters (10)

  • CGMP/Active Pharmaceutical Ingredient (API)/Adulterated/Misbranded

    Darmerica, LLC

    2025-12-23
  • OTC/Unapproved New Drug/Misbranded

    Supergoop!

    2025-08-12
  • OTC/Unapproved New Drug/Misbranded

    K & Care Organics

    2025-08-12
  • OTC/Unapproved New Drug/Misbranded

    Fallien Cosmeceuticals Ltd. dba Fallene Ltd.

    2025-08-12
  • Failure to List/Misbranded

    Shenzhen Hengkaifeng Commerce and Trade Co., Ltd

    2025-05-27
  • Electronic Drug Registration and Listing System (eDRLS)/Violations

    Prodose, Inc. formerly known as Spirit Pharmaceuticals LLC

    2025-04-29
  • CGMP/Finished Pharmaceutical/Adulterated

    Jagsonpal Pharmaceuticals Limited

    2025-02-18
  • CGMP/Finished Pharmaceuticals/Adulterated/Misbranded/Failure to Register

    Omni Lens Pvt. Ltd.

    2024-10-22
  • Failure to Register and List

    Media Networks Sydney Pty Limited

    2024-08-20
  • Failure to Register and List

    Zen Enterprises LLC

    2024-04-23

See Also (8)

Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors | Guideline Explorer | BioRegHub