Use One Tablet Size for Each Oral Medication

​Many oral medications are available in a variety of tablet sizes, even for the same dosage. This can cause confusion for staff and patients. Staff and patients often use visual recognition, to identify and differentiate drugs. Errors in visual identification often go undetected and lead to other errors. Because visual recognition has a huge risk of error, it should never be the sole means of identification. To minimize this risk, a health care organization should select one tablet size for each dosage of each oral medication and dispense that size consistently.



  • Educate patients about tablet size issues, as they may receive a different size from outpatient or retail pharmacies.
  • Remember that tablet color and shape can also play a role in visual identification errors.
  • Dispense oral medications in ready-to-use single doses, so staff do not have to count tablets.
  • Ensure that dispensed doses are the exact amount required, so staff do not need to cut tablets.


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