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.

QUICKLINKS:

Latest Alerts

Oxytocin, Ondansetron, Phenylephrine, Metoclopramide
September 1, 2026

In the Pyxis in the ORs on labor and delivery.

Oxytocin, Ondansetron, Phenylephrine, Metoclopramide

Submitted by
Stanley Thornton, MD

Potassium Phosphate, Mepivacaine
August 27, 2026

Potassium phosphate and mepivacaine vials.

Potassium Phosphate, Mepivacaine

Submitted by
Kati Forbes, PharmD

Furosemide, Norepipnephrine
August 4, 2026

Very resembling Furosemide and Norepipnephrine, you don’t really want to use one when you need the other.

Furosemide, Norepipnephrine

Furosemide, Norepipnephrine

Submitted by
Yonathan Delouya, MD
Jackson Memorial Hospital, Miami, FL

Atropine Sulfate, Naloxone Hydrochloride
July 27, 2026

This is the most similar Look-Alike pair I have personally seen in my whole career. Thank you for letting others know!

Atropine Sulfate, Naloxone Hydrochloride

Submitted by
Mark Gjolaj, MD, MBA
Kaiser Permanente

Ketorolac, Dexamethasone
July 12, 2026

Strikingly similar ketorolac and dexamethasone vials in adjacent medication bins.

Vials Bin – Ketorolac, Dexamethasone

Vials Front – Ketorolac, Dexamethasone

Vials Back – Ketorolac, Dexamethasone

Submitted by
Hedwig Schroeck, MD, FAAP
Dartmouth Health, Lebanon, New Hampshire, USA

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

Searchable Look-Alike Drug Vials Gallery

Filter

• -All (94)
• -Country: Canada (3)
• -Country: France (1)
• -Country: Japan (7)
• -Country: Mexico (1)
• -Country: Netherlands (2)
• -Country: New Zealand (1)
• -Country: United Kingdom (8)
• -Country: United States (65)
• Acetaminophen (6)
• Adenosine (1)
• Amiodarone (1)
• Atropine (4)
• Bupivacaine (9)
• Caffeine and Sodium Benzoate (1)
• Calcium Chloride (1)
• Calcium Gluconate (1)
• Carboprost Tromethamine (1)
• Cefazolin (1)
• Chloroprocaine Hydrochloride (1)
• Clonidine Hydrochloride (1)
• Cupric Chloride (1)
• Dexamethasone (7)
• Dexmedetomidine (5)
• Diphenhydramine (1)
• Ephedrine (5)
• Epinephrine (5)
• Estradiol (1)
• Etomidate (2)
• Fentanyl (2)
• Flumazenil (1)
• Furosemide (2)
• Glycopyrrolate (6)
• Heparin (1)
• Hydralazine (6)
• Ketamine (1)
• Ketorolac (3)
• Levobupivacaine (4)
• Levophed Norepinephrine Bitartrate (1)
• Lidocaine (11)
• Magnesium Sulphate (1)
• Mepivacaine (3)
• Metamizol (1)
• Metoclopramide (3)
• Metronidazole (1)
• Midazolam (2)
• Naloxone (6)
• Nicardipine (2)
• Neostigmine (5)
• Norepipnephrine (1)
• Ondansetron (11)
• Oxytocin (3)
• Paracetamol (1)
• Phenylephrine (10)
• Potassium Phosphate (1)
• Propofol (1)
• Protamine Sulfate (1)
• Rocuronium (6)
• Sodium Chloride (5)
• Succinylcholine (5)
• Sugammadex (2)
• Suxamethonium (1)
• Tamoxifen Citrate (1)
• Terbutaline Sulfate (1)
• Tranexamic Acid (7)
• Triamcinolone (1)
• Vasopressin (3)
• Vazculep (1)
• Verapamil (3)
• Zinc Chloride (1)

Oxytocin, Ondansetron, Phenylephrine, Metoclopramide

-Country: United States, Ketorolac, Mepivacaine, Metamizol, Metronidazole

Potassium Phosphate, Mepivacaine

-Country: United States, Hydralazine, Zinc Chloride

Furosemide, Norepipnephrine

-Country: United States, Epinephrine, Verapamil

Atropine Sulfate, Naloxone Hydrochloride

-Country: United States, Adenosine, Lidocaine

Ketorolac, Dexamethasone

-Country: United States, Carboprost Tromethamine, Vazculep

Ketorolac, Dexamethasone

-Country: United States, Carboprost Tromethamine, Vazculep

Ketorolac, Dexamethasone

-Country: United States, Carboprost Tromethamine, Vazculep

Dexamethasone, Naloxone

Carboprost Tromethamine, Lidocaine

Succinylcholine, Rocuronium Bromide

-Country: United States, Naloxone, Neostigmine

Vasopressin, Acetaminophen

-Country: United States, Acetaminophen, Propofol

Succinylcholine, Ephedrine

-Country: United States, Chloroprocaine Hydrochloride, Neostigmine

Adenosine, Amiodarone

-Country: United States, Triamcinolone, Vasopressin

Dexamethasone

-Country: United States, Carboprost Tromethamine

Ondansetron

-Country: United States, Mepivacaine

Metoclopramide

-Country: United States, Ketorolac

Lidocaine, Rocuronium, Succinylcholine

-Country: United States, Glycopyrrolate, Naloxone, Neostigmine

Cupric Chloride, Zinc Chloride

-Country: United States, Terbutaline Sulfate, Tranexamic Acid

Heparin, Verapamil

-Country: United States, Etomidate, Rocuronium

Lidocaine, Etomidate

-Country: United States, Dexamethasone, Glycopyrrolate

Sugammadex, Caffeine and Sodium Benzoate

-Country: United States, Tamoxifen Citrate, Norepipnephrine

Cefazolin, Flumazenil

-Country: United States, Caffeine and Sodium Benzoate, Ephedrine

Naloxone, Diphenhydramine

Suxamethonium, Lidocaine

Naloxone, Vasopressin

Lidocaine, Propofol

Carboprost Tromethamine

-Country: United States, Sugammadex

Ondansetron, Ephedrine Sulfate

-Country: United States, Chloroprocaine Hydrochloride, Mepivacaine

Sodium Chloride Injection, Sodium Chloride Irrigation

Nicardipine

Lidocaine, Oxytocin

-Country: United States, Glycopyrrolate, Metamizol

Ondansetron, Dexmedetomidine, Lidocaine

-Country: United States, Cefazolin, Glycopyrrolate, Mepivacaine

Hydralazine, Ondansetron

-Country: United States, Famotidine, Mepivacaine

Bupivacaine, Neostigmine Methylsulfate

-Country: United States, Amiodarone, Magnesium Sulphate

Tranexamic Acid, Bupivacaine

-Country: United States, Amiodarone, Phenylephrine

Phenylephrine, Hydralazine

-Country: United States, Famotidine, Metronidazole

Propofol, Omegaven

-Country: United States, Succinylcholine

Sterile Water for Injection USP 1000ml, Lactated Ringer’s Injection USP 1000ml

-Country: United States

Neostigmine, Lidocaine

-Country: United States, Glycopyrrolate, Magnesium Sulphate

Acetaminophen, Nicardipine

-Country: United States, Acetaminophen, Sodium Chloride

Acetaminophen, Nicardipine

-Country: United States, Acetaminophen, Sodium Chloride

Epinephrine, Neostigmine

-Country: Japan, Clonidine Hydrochloride, Magnesium Sulphate

Succinylcholine, Rocuronium

-Country: United States, Naloxone, Neostigmine

Tranexamic Acid, Bupivacaine

-Country: Netherlands, Amiodarone, Phenylephrine

Vasopressin, Hydralazine

-Country: Canada, Famotidine, Propofol

Suxamethonium, Metamizol

-Country: Netherlands, Ketamine, Ondansetron

Rocuronium, Sugammadex

-Country: France, Naloxone, Norepipnephrine

Glycopyrronium Bromide, Clonidine Hydrochloride

-Country: New Zealand, Calcium Gluconate, Estradiol

Epinephrine, Verapamil

-Country: United States, Clonidine Hydrochloride, Rocuronium

Acetaminophen, Levobupivacaine

-Country: Japan, Acetaminophen, Flumazenil

Acetaminophen, Levobupivacaine

-Country: Japan, Acetaminophen, Flumazenil

Epinephrine, Glycopyrrolate

-Country: United States, Clonidine Hydrochloride, Estradiol

Lidocaine, Bupivacaine

-Country: United States, Amiodarone, Glycopyrrolate

Ondansetron, Dexmedetomidine

-Country: United States, Cefazolin, Mepivacaine

Bupivacaine, Sodium Chloride

-Country: United Kingdom, Amiodarone, Nicardipine

Lidocaine, Dexmedetomidine

-Country: United States, Cefazolin, Glycopyrrolate

Protamine Sulfate, Glycopyrrolate

-Country: United States, Estradiol, Midazolam

Mepivicaine (Polocaine), Calcium Chloride

-Country: United States, Atropine, Hydralazine

TXA, Hyperbaric Bupivacaine, Isobaric Bupivacaine

-Country: Japan, Amiodarone, Phenylephrine

Mepivacaine, TXA

-Country: Japan, Hydralazine, Phenylephrine

TXA, Levobupivacaine

-Country: Japan, Flumazenil, Phenylephrine

NRFit, Syringe Does Not Fit the Vial Inlet

-Country: Japan

Calcium Gluconate, Sodium Chloride

-Country: United Kingdom, Bupivacaine, Nicardipine

Paracetamol, Metronidazole

-Country: United Kingdom, Levobupivacaine, Metoclopramide

Magnesium Sulphate, Water

-Country: United Kingdom, Heparin

Levobupivacaine (Chirocaine), Sodium Chloride

-Country: United Kingdom, Flumazenil, Nicardipine

Bupivacaine, Sodium Chloride

-Country: United Kingdom, Amiodarone, Nicardipine

Succinylcholine Chloride, Rocuronium Bromide

-Country: United States, Naloxone, Neostigmine

Tranexamic Acid, Chloroprocaine Hydrochloride

-Country: Canada, Calcium Chloride, Phenylephrine

Phenylephrine Hydrochloride, Dexmedetomidine Hydrochloride

-Country: Canada, Cefazolin, Metronidazole

Furosemide Injection, Levophed Norepinephrine Bitartrate

-Country: United States, Epinephrine, Furosemide

Dehydrated Alcohol, Fentanyl

-Country: United Kingdom, Diphenhydramine

Ephedrine Sulfate, Adrenalin

-Country: United States, Chloroprocaine Hydrochloride, Clonidine Hydrochloride

Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide

-Country: United States, Estradiol, Ketorolac, Mepivacaine, Metamizol, Metronidazole

Glycopyrrolate, Hydralazine

-Country: United States, Estradiol, Famotidine

Ephedrine Sulfate Injection, Adrenalin

-Country: United States, Chloroprocaine Hydrochloride, Clonidine Hydrochloride

Acetaminophen, Dexmedetomidine

-Country: United States, Acetaminophen, Cefazolin

Pisacaina 2% – Lidocaina, Diluyenta

-Country: Mexico, Glycopyrrolate

Naloxone Hydrochloride Injection, Fentanyl Citrate Injection

Diphenhydramine, Lidocaine

Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection

-Country: United States, Magnesium Sulphate, Metronidazole

Estradiol, Tamoxifen Citrate

-Country: United States, Cupric Chloride, Oxytocin

Vazculep, Neostigmine Methylsulfate Injection

-Country: United States, Magnesium Sulphate, Protamine Sulfate

PHENYLephrine HCI, ePHEDrine Sulfate

-Country: United States, Chloroprocaine Hydrochloride, Metronidazole

HydrALAZINE Hydrochloride Injection, Ondansetron Injection, Atropine Sulfate Injection

-Country: United States, Adenosine, Famotidine, Mepivacaine

Bupivacaine HCI Injection, Lidocaine HCI Injection

-Country: United States, Amiodarone, Glycopyrrolate

Midazolam, Rocuronium Bromide

-Country: United Kingdom, Levophed Norepinephrine Bitartrate, Naloxone

Terbutaline Sulfate Injection, Dexamethasone Sodium Phosphate Injection

-Country: United States, Carboprost Tromethamine, Paracetamol

Tranexamic Acid Injection, Bupivacaine HCI Injection

-Country: United States, Amiodarone, Phenylephrine

HydrALAZINE Hydrochloride, Phenylephrine HCI Injection

-Country: United States, Famotidine, Metronidazole

Robinul {Glycopyrrolate} – Triamcinolone Look-Alike Vials July 22, 2021 We use the pyxis anesthesia workstations. The provider selected to pull three 0.2mg vials of robinul as he was preparing to reverse the patient muscle relaxant. When he put in the quantity of three, the draw opened and he pulled out the medication. In the first and third slot there was Robinul {Glycopyrrolate} 0.2mg vials as expected however, in slot 2 was a vial of triamcinolone 40mg. The photos below show how similar the vials look. The provider recognized the difference and returned the medication to the pharmacy. As we are all well aware it is during this time when things can become busy for us as we prepare to wake the patient and extubate. I feel many people may have missed this as they would look at the first vial, see it’s correct, and begin pulling up the medication in the next 2 vials while they are adjusting gas flows, assessing the paralytic, checking suction, and how close the surgeon is to finishing……? Submitted by Timothy Flint DNAP, CRNA Director of Anesthesia Ascension Southfield and Novi

-Country: United States, Estradiol, Potassium Phosphate

Phenylephrine 1% 1mL vial paired next to Ondansetron (Zofran®) 4mg 2mL vial. Look-alike with blue tops.

-Country: United States, Mepivacaine, Metronidazole

Four vials with similar blue tops paired next to each other in same drawer. Etomidate (Amidate®), Phenylephrine, Lidocaine and dexamethasone.

-Country: United States, Carboprost Tromethamine, Dexamethasone, Glycopyrrolate, Metronidazole

Phenylephrine 1% 1mL vial fell into Ondansetron (Zofran®) 4mg 2mL vial drawer. This is from a different institution than Figure 1. Look-alike with blue tops.

-Country: United States, Mepivacaine, Metronidazole

Oxytocin (Pitocin), Ondansetron (Zofran ®) 4 mg/2mL, and metoclopramide vial look-alike with similar green tops.

-Country: United States, Ketorolac, Mepivacaine, Metamizol

Midazolam 2mg/2mL and Ketamine Hydrochloride 100mg/2mL Look-alike with similar shade orange tops.

-Country: United States, Fentanyl, Levophed Norepinephrine Bitartrate

Phenylephrine 1% 1mL vial paired next to Ondansetron (Zofran®) 4mg 2mL vial and Atropine sulfate 1mg/mL vials. Look-alike with blue tops.

-Country: United States, Adenosine, Mepivacaine, Metronidazole

Verapamil 2.5mg/mL versus naloxone 0.4 mg/mL look-alike vials with similar maroon tops.

-Country: United States, Lidocaine, Rocuronium

Atropine 0.4 mg/mL versus Lidocaine 20 mg/mL vial look-alike pairing with teal tops.

-Country: United States, Adenosine, Glycopyrrolate

APSF Articles and Media

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

APSF Podcasts

• Episode #54 Medication Safety and Look-alike Vials
• Episode #55 Be on the Look-out for Look-alike Vials

APSF Videos

• APSF Stoelting Conference Patient Safety Presentation: FDA and Generic Drug Labeling Updates

Submit a Look-Alike Drug Alert