The following alerts and photos show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety.
Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection
June 3, 2022
Concentrated phenylephrine and neostigmine vials and color schemes nearly identical.
Christopher Seiter, DO
Stony Brook Medicine
Estradiol, Tamoxifen Citrate
April 4, 2022
[Drug mix-up administration can be even more troublesome] because tamoxifen is used after breast cancer to decrease estrogen, and [this vial is simply] exogenous estrogen.
Emahn Wilder, PharmD
Ephedrine, Phenylephrine, Metoclopramide, Famotidine | Cefazolin, Flumazenil | Tranexamic Acid Injection (same medication labeled with multiple colors) | Atropine Sulfate, Ondansetron, Dexmedetomidine | Heparin Sodium Injection, Calcium Gluconate
April 2, 2022
Latest look-a-likes in our drug drawer!
Janette McVey, MD
University of Missouri Healthcare
APSF Newsletter Articles
- Important Medication Errors and Hazards Reported to the ISMP National Medication Errors Reporting Program During 2020
- Letter to the Editor: Medication Error Related to Look-Alike Prefilled Syringes
- Letter to the Editor: Should Medication Labels be Color-Coded?
- RAPID Response: “No Read” Errors Related to Prefilled Syringes
- The Call for Standardizing Safer Drug Labeling Methods
- Pro/Con Debate: Color-Coded Medication Labels
PRO: Color-Coded Medication Labels Improve Patient Safety
CON: Anesthesia Drugs Should NOT Be Color-Coded
- Episode #54 Medication Safety and Look-alike Vials
- Episode #55 Be on the Look-out for Look-alike Vials