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
Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide
November 25, 2022
Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide
Submitted by
Christina Menor, MD
Hollywood Presbyterian Medical Center
Glycopyrrolate, Hydralazine
November 21, 2022
Glycopyrrolate, Hydralazine
Hydralazine vials found in Glycopyrrolate bin. Different caps, yet similar in size and coloration.
Submitted by
Catherine Ramsey, CRNA
Beebe Healthcare
Ephedrine Sulfate Injection, Adrenalin
October 31, 2022
Ephedrine Sulfate Injection, Adrenalin
This is from a surgery center where medications are in a drawer next to each other.
Submitted by
Christina Menor, MS, MD
Hollywood Presbyterian Medical Center
Acetaminophen, Dexmedetomidine
October 17, 2022
Acetaminophen, Dexmedetomidine
Post-procedure, similarity between Acetaminophen and Dexmedetomidine (picture above) vials led to accidental administration of the latter resulting in bradycardia and hypertension. After appropriate resuscitation and care, the patient was discharged home safely without any postoperative complications same day. Full disclosure of the event and the error was discussed with the patient and family. We also initiated a risk-management case and pharmacy was made aware of the error.
Submitted by
Kirolos Sami, MD and Sumit Singh, MD
UCLA, Greater Los Angeles VA
Pisacaina 2% – Lidocaina, Diluyenta
October 6, 2022
Pisacaina 2% – Lidocaina, Diluyenta
This 2 vials are commonly in the OR in Mexico.
Submitted by
Fernando Antonio Escudero Gutierrez, Anesthesiologist
Naloxone Hydrochloride Injection, Fentanyl Citrate Injection
September 7, 2022
Naloxone Hydrochloride Injection, Fentanyl Citrate Injection
Submitted by
Sara Jordan Hyland, PharmD
OhioHealth Grant Medical Center
Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection
June 3, 2022
Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection
Concentrated phenylephrine and neostigmine vials and color schemes nearly identical.
Submitted by
Christopher Seiter, DO
Stony Brook Medicine
Estradiol, Tamoxifen Citrate
April 4, 2022
Estradiol, Tamoxifen Citrate
[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.
Submitted by
Emahn Wilder, PharmD
Midwestern University
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!
Ephedrine, Phenylephrine, Metoclopramide, Famotidine
Cefazolin, Flumazenil
Tranexamic Acid Injection (same medication labeled with multiple colors)
Atropine Sulfate, Ondansetron, Dexmedetomidine (same medication labeled with multiple colors)
Heparin Sodium Injection, Calcium Gluconate
Submitted by
Janette McVey, MD
University of Missouri 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