Dr. Schranz makes many good points about some of the causes for drug error in the operating room (OR). There are many distractions, and production pressure is also a major cause, I am sure. No time to "read" the label, only time to recognize the color and shape pattern.
It just seems to me that the human mind is rather adept at, and seemingly eager to use, pattern recognition for many visual tasks in and out of the OR. It is, perhaps, easier than reading the small print on the label, less time consuming, and works well, but sometimes not so very well, if your glasses are smudged or bespattered or you can't hear the surgeon well over the cacophony of sound and fury that is the modern day, boom box embattled OR.
So, eliminate the pattern, force all attention to the label and the letters printed on it. Perhaps it can serve as a small step forward in the perpetual effort to eliminate drug error.