Look-Alike Drug Vials: Latest Stories & Gallery

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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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

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