The following alerts and photos show how look-alike drug vials and packaging can contribute to medication errors and impact patient safety.
Estradiol, Tamoxifen Citrate
April 4, 2022
[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.
Emahn Wilder, PharmD
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!
Janette McVey, MD
University of Missouri Healthcare
Vazculep, Neostigmine Methylsulfate Injection
March 4, 2022
Pharmacy is now stocking 5 ml vials of concentrated phenylephrine in our top drawer.
Jennifer Jones, CRNA
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