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

Glycopyrronium Bromide, Clonidine Hydrochloride
June 20, 2024

Glycopyrronium Bromide 200mcg/mL vs Clonidine Hydrochloride 150mcg/mL

Glycopyrronium Bromide, Clonidine Hydrochloride

Glycopyrronium Bromide, Clonidine Hydrochloride

Submitted by
Michael J. Barlev, MBBS, FANZCA
Health New Zealand Southern


Epinephrine, Verapamil
February 26, 2024

Epinephrine vials in our institution are often placed in a labeled bag as pictured. While in the process of preparing an epinephrine infusion, a vial of verapamil was found to be amongst the epinephrine vials within the epinephrine labeled bag. Verifying the drug name on each vial prevented what could have been a catastrophic event in a patient who required vasopressor support.

Epinephrine, Verapamil

Epinephrine, Verapamil

Submitted by
Jay Majmundar MD; Peter Shapiro MD
Hackensack University Medical Center


Acetaminophen, Levobupivacaine
February 16, 2024

The bag on the left is intravenous acetaminophen, and the bag on the right is 0.2% levobupivacaine. As the bag of levobupibacaine has a hook for hanging the bag for the preparation, it causes accidental local anesthetic toxicity.

https://www.medsafe.or.jp/uploads/uploads/files/teigen15.pdf

If the levobupivacaine bag omits the hook, the accident would be avoidable.

Acetaminophen, Levobupivacaine

Acetaminophen, Levobupivacaine

Acetaminophen, Levobupivacaine

Acetaminophen, Levobupivacaine

Submitted by
Yusuke Mazda, MD, PhD
Saitama Medical Center, Saitama Medical University


Epinephrine, Glycopyrrolate
January 30, 2024

Epinephrine, Glycopyrrolate

Epinephrine, Glycopyrrolate

Submitted by
Cheryl Hamel


Lidocaine, Bupivacaine
January 19, 2024

Lidocaine (used IV at induction) and bupivacaine look very similar from the same manufacturer. Red caps for many manufacturers denote the addition of epinephrine but do not in this case.

Lidocaine, Bupivacaine

Lidocaine, Bupivacaine

Submitted by
Megan Anders, MD, MS
University of Maryland


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