Look-Alike Drug Vials: Latest Stories & Gallery

Look-Alike Drug Vials

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

Carboprost Tromethamine
May 21, 2025

Found hemabate (carboprost tromethamine) injection stored in spinal marcaine compartment. Both are 1 mL ampules. Discovered by double checking label prior to use.

OB, not anesthesia, stores hemabate. One way it could’ve entered the anesthesia cart is from someone cleaning up and replacing unused vials without checking.

Carboprost Tromethamine

Carboprost Tromethamine

Submitted by
Peter Jong, MD
Kaiser Permanente


Ondansetron, Ephedrine Sulfate
May 19, 2025

Ondansetron 4mg/2mL & Ephedrine 50mg/mL both with green caps found stocked next to each other in the medication drawer. One would not want to mix up these antiemetic and vasopressor vials.

Ondansetron, Ephedrine Sulfate

Ondansetron, Ephedrine Sulfate

Submitted by
Amanda Milburn, DO
St. Joseph’s Regional Medical Center


Sodium Chloride Injection, Sodium Chloride Irrigation
May 18, 2025

Normal saline for IV administration and normal saline for irrigation. Normal saline for irrigation should never be administered intravenously.

Sodium Chloride Injection, Sodium Chloride Irrigation

Sodium Chloride Injection, Sodium Chloride Irrigation

Submitted by
Anonymous


Lidocaine, Oxytocin
May 5, 2025

2% Lidocaine and Oxytocin in the same bin. Caught before administration.

Lidocaine, Oxytocin

Lidocaine, Oxytocin

Submitted by
Taylor Tribett, MD
Vassar Brothers Medical Center


Ondansetron, Dexmedetomidine, Lidocaine
April 4, 2025

These 3 look-alike vials were sent to me in my role with QI & safety by one of our pharmacists so that our team would be aware. After he sent the photo, another team member said that someone had taken out a vial of diphenhydramine (not pictured) that they thought was concentrated Dexmedetomidine. Thankfully that was caught before administration.

Ondansetron, Dexmedetomidine, Lidocaine

Ondansetron, Dexmedetomidine, Lidocaine

Submitted by
Cathie Jones, MD
Boston Children’s Hospital


Hydralazine, Ondansetron
April 2, 2025

Hydralazine accidentally stocked in Zofran bin; lookalike.

Hydralazine, Ondansetron

Hydralazine, Ondansetron

Submitted by
Eric Fleck, CRNA


Tranexamic Acid, Bupivacaine, Neostigmine Methylsulfate
February 20, 2025

This photo highlights how vials of Tranexamic Acid 1000mg/10mL and Bupivacaine 0.5% 50mg/10mL look very similar. Both of these medications having yellow caps could easily cause a stocking error in a drug tray or automated dispensing cabinet leading to a potentially fatal drug error. Both vials are often out and used during orthopedic cases, therefore, these two look alike vials pose an incredibly high risk of a swapping error. The FDA is currently conducting a safety evaluation and is investigating the issue of tranexamic acid injection being erroneously administered intrathecally instead of the intended intrathecal (spinal) anesthetic (e.g., bupivacaine injection) for neuraxial anesthesia.

Tranexamic Acid, Bupivacaine

Tranexamic Acid, Bupivacaine

Here is an example of two 10mL vials with white and blue labels and blue top caps. One medication is used for neuromuscular blockade reversal and the other is a local anesthetic. These two vials could easily be swapped. Caution must always be taken to read vial labels in their entirety when administering medications to prevent drug errors.

Bupivacaine, Neostigmine Methylsulfate

Bupivacaine, Neostigmine Methylsulfate

Submitted by
Jonathan Markley, DO
St. Joseph’s University Medical Center


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