RT Journal Article SR Electronic T1 Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS JF BMJ Case Reports JO BMJ Case Reports FD BMJ Publishing Group Ltd SP bcr-2018-227468 DO 10.1136/bcr-2018-227468 VO 11 IS 1 A1 Edington, Magdalena A1 Connolly, Julie A1 Lockington, David YR 2018 UL http://casereports.bmj.com/content/11/1/bcr-2018-227468.abstract AB We wish to report an ocular chemical injury caused by inadvertent dispensing and administration of an erectile dysfunction cream (Vitaros) instead of an ocular lubricant (VitA-POS) to highlight this potential source of error. Prescribing errors are common, and medications with similar names/packaging increase risk. However, it is unusual in this case that no individual (including the patient, general practitioner or dispensing pharmacist) questioned erectile dysfunction cream being prescribed to a female patient, with ocular application instructions. The patient was treated for a mild ocular chemical injury with topical antibiotics, steroids and lubricants, with good response. However, we believe this to be an important issue to report to enhance awareness and promote safe prescribing skills.