The following alerts and photos show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety.
Tranexamic Acid Injection, Bupivacaine HCI Injection
August 24, 2021
While working on Labor and Delivery unit, it is not uncommon a nurse will bring medication to the room for epidural administration. The Tranexamic Acid (TXA) vial and Bupivicaine vial are next to one another in the medication dispenser. They are similar in appearance minus the res portion of front label.
Andrea Regan, MScS, MSA, CAA
HydrALAZINE Hydrochloride, Phenylephrine HCI Injection
August 23, 2021
Today I found Hydralizine and Phenylephrine vials intermixed. These two medications sit adjacent to each other in our Omnicell. …[T]he vials change regularly to include different sizes and colors…
Paul Packard, DNAP, CRNA, CPPS
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
- Episode #54 Medication Safety and Look-alike Vials
- Episode #55 Be on the Look-out for Look-alike Vials