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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Mannitol, Sodium Chloride
October 3, 2026

Look alike –
Mannitol 20% W/V, 100 ml Company: Fresenius
3% NaCl, 100 ml, Company: IHL Lifesciences

Mannitol, Sodium Chloride

Submitted by
Karru Venkata Ravi Teja, MD, PhD
RMD Chennai, India

Sugammadex, Vasopressin
September 26, 2026

Vasopressin and sugammadex are supplied in the same size vials with orange caps in the main OR.

Sugammadex, Vasopressin

Submitted by
Amanda Milburn
Northwell Cohen Children’s Medical Center

Oxytocin, Ondansetron, Phenylephrine, Metoclopramide
September 1, 2026

In the Pyxis in the ORs on labor and delivery.

Oxytocin, Ondansetron, Phenylephrine, Metoclopramide

Submitted by
Stanley Thornton, MD

Potassium Phosphate, Mepivacaine
August 27, 2026

Potassium phosphate and mepivacaine vials.

Potassium Phosphate, Mepivacaine

Submitted by
Kati Forbes, PharmD

Furosemide, Norepipnephrine
August 4, 2026

Very resembling Furosemide and Norepipnephrine, you don’t really want to use one when you need the other.

Furosemide, Norepipnephrine

Submitted by
Yonathan Delouya, MD
Jackson Memorial Hospital, Miami, FL

Atropine Sulfate, Naloxone Hydrochloride
July 27, 2026

This is the most similar Look-Alike pair I have personally seen in my whole career. Thank you for letting others know!

Atropine Sulfate, Naloxone Hydrochloride

Submitted by
Mark Gjolaj, MD, MBA
Kaiser Permanente

Ketorolac, Dexamethasone
July 12, 2026

Strikingly similar ketorolac and dexamethasone vials in adjacent medication bins.

Vials Bin – Ketorolac, Dexamethasone

Vials Front – Ketorolac, Dexamethasone

Vials Back – Ketorolac, Dexamethasone

Submitted by
Hedwig Schroeck, MD, FAAP
Dartmouth Health, Lebanon, New Hampshire, USA

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