A woman has been injured after mistakenly being prescribed an erectile dysfunction cream for her eye.
Erectile dysfunction cream 'Vitaros' was given to her instead of eye lubricant 'VitA-POS'.
The event has been highlighted in the British Medical Journal (BMJ).
It says: "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.
It adds that she was treated for a mild chemical injury to her eye with topical antibiotics, steroids and lubricants.
It says she had a "good response" to the treatments.
But it believes this was "an important issue to report to enhance awareness and promote safe prescribing skills."
One suggested remedy is the use of block capitals in handwritten prescriptions to avoid similar situations.
The unnamed patient is from Glasgow in Scotland.