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
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
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
Submitted by
Anonymous
Lidocaine, Oxytocin
May 5, 2025
2% Lidocaine and Oxytocin in the same bin. Caught before administration.
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
Submitted by
Cathie Jones, MD
Boston Children’s Hospital
Hydralazine, Ondansetron
April 2, 2025
Hydralazine accidentally stocked in Zofran bin; lookalike.
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
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
Submitted by
Jonathan Markley, DO
St. Joseph’s University Medical Center
Searchable 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
