Look-Alike Drug Vials: Latest Stories & Gallery

The following alerts and photos show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety.

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Dexamethasone, Naloxone
June 12, 2026

The vial of dexamethasone and naloxone are much alike

Dexamethasone, Naloxone

Submitted by
Ana Margarida zeferino de Sousa Gaspar
Instituto português de oncologia de Lisboa, Francisco gentil

Succinylcholine, Rocuronium Bromide
April 3, 2026

These two paralytics have distinct mechanisms of action, durations, and contraindications, thus their vials should have well established visual differences. Accidental vial swaps of these two medications could potentially be catastrophic.

Succinylcholine, Rocuronium Bromide

Submitted by
Jeremy Grayson
St. Joseph’s University Medical Center Paterson, NJ

Vasopressin, Acetaminophen
February 13, 2026

Mix-ups between IV acetaminophen and vasopressin have occurred due to their similar presentation, leading to an incident in which patients intended to receive vasopressin received IV acetaminophen instead.

Vasopressin, Acetaminophen

Submitted by
Bruna Maria Castro de Oliveira, MD
Massachusetts General Hospital

Succinylcholine, Ephedrine
December 31, 2025

Succinylcholine vials made by Hikma (NDC: 0143-9338-25) have a yellow cap, which is a departure from the unofficial standard practice of using red caps for succinylcholine.

These yellow-capped succinylcholine vials with orange labeling are strikingly similar to ephedrine vials, as shown in the attached photo.

Succinylcholine, Ephedrine

Submitted by
Perry Shafner, PharmD
Greater Baltimore Medical Center

Adenosine, Amiodarone
December 29, 2025

These two vials of Adenosine and Amiodarone were stored next to each other in a crash cart. The adenosine manufacturer was recently updated, resulting in the look-alike packaging. Adenosine was pulled in error during a code blue, but the error was detected before reaching the patient.

Adenosine, Amiodarone

Submitted by
Erin Gavin, PharmD
Prime Healthcare

Ondansetron, Metoclopramide, Dexamethasone
December 22, 2025

Not quite the same, but multiple different appearing versions of commonly used drugs in our drug cabinet: ondansetron (3), metoclopramide (2), dexamethasone (2)

Drug Cabinet

Ondansetron

Metoclopramide

Dexamethasone

Submitted by
Christine Doyle, MD
O’Connor Hospital, Santa Clara Valley Healthcare

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