Look-Alike Drug Vials: Latest Stories & Gallery

Look-Alike Drug Vials

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

Propofol, Omegaven
December 19, 2024

Can be confused with propofol in stocking. Omegaven: Most common adverse drug reactions (>15%) are: vomiting, agitation, bradycardia, apnea and viral infection. Not a general anesthetic drug.

Propofol, Omegaven

Propofol, Omegaven

Submitted by
Richard J. Pollard, MD, FASA
Beth Israel Deaconess Medical Center, Boston, MA


Sterile Water for Injection USP 1000ml, Lactated Ringer’s Injection USP 1000ml
October 30, 2024

Sterile Water for Injection USP 1000ml vs Lactated Ringer’s Injection USP 1000ml – both bags are manufactured by Braun

Sterile Water for Injection USP 1000ml, Lactated Ringer's Injection USP 1000ml

Sterile Water for Injection USP 1000ml, Lactated Ringer’s Injection USP 1000ml

Submitted by
Caitlin Houtchens
Cross Timbers Surgery Center


Neostigmine, Lidocaine
September 4, 2024

Neostigmine, an acetylcholinesterase inhibitor compared to lidocaine, a local anesthetic.

Due to market volatility with generic injectable manufacturers, we are frequently forced to buy vials from multiple companies. This results in intermittent similarities beyond our control, making vigilance a key priority until barcode scanning technology becomes standard.

Neostigmine, Lidocaine

Neostigmine, Lidocaine

Submitted by
Charles Sims, MD
Mayo Clinic, Rochester


Acetaminophen, Nicardipine
August 9, 2024

Acetaminophen IV and Nicardipine infusion look similar in external wrapper as well as when wrapper is off.

Acetaminophen, Nicardipine

Acetaminophen, Nicardipine

Acetaminophen, Nicardipine

Acetaminophen, Nicardipine

Submitted by
Patricia Fogarty Mack, MD
Weill Cornell Medicine


Epinephrine, Neostigmine
July 26, 2024

Epinephrine 1mg (left) and neostigmine 0.5mg (right).

Epinephrine, Neostigmine

Epinephrine, Neostigmine

Submitted by
Yuki Kuruma, MD
Saiseikai Matsusaka General Hospital


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