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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Latest Alerts
Ephedrine Sulfate, Adrenalin
February 26, 2023
Recurrent issue and our meds are in open drawers bc ASC doesn’t have Omnicell.
Submitted by
Christina Menor, MS, MD, FASA
Private Practice ASC
Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide
November 25, 2022
Submitted by
Christina Menor, MD
Hollywood Presbyterian Medical Center
Glycopyrrolate, Hydralazine
November 21, 2022
Hydralazine vials found in Glycopyrrolate bin. Different caps, yet similar in size and coloration.
Submitted by
Catherine Ramsey, CRNA
Beebe Healthcare
Look-Alike Drug Vials Gallery
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