Presents a case involving an 82-year-old woman with type 2 diabetes admitted with acute renal failure who was taking incorrect medication. Determination that the medication which was given to her by a pharmacist was captopril 25 mg tablets when it should have been gliclazide 80 mg tablets; Findings that showed both tablets have identical shape and markings although made by different manufacturers and contain different drugs; Conclusion that many elderly patients use pill boxes with the external packaging of the medication removed and that the appearance of different medications needs to be specific and that clinicians and pharmacists need to be aware of this situation.
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