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

Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide
November 25, 2022

Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide

Oxytocin, Glycopyrrolate, Ondansetron, Phenylephrine, Metoclopramide

Submitted by
Christina Menor, MD
Hollywood Presbyterian Medical Center


Glycopyrrolate, Hydralazine
November 21, 2022

Glycopyrrolate, Hydralazine

Glycopyrrolate, Hydralazine

Hydralazine vials found in Glycopyrrolate bin. Different caps, yet similar in size and coloration.

Submitted by
Catherine Ramsey, CRNA
Beebe Healthcare


Ephedrine Sulfate Injection, Adrenalin
October 31, 2022

Ephedrine Sulfate Injection, Adrenalin

Ephedrine Sulfate Injection, Adrenalin

This is from a surgery center where medications are in a drawer next to each other.

Submitted by
Christina Menor, MS, MD
Hollywood Presbyterian Medical Center


Acetaminophen, Dexmedetomidine
October 17, 2022

Acetaminophen, Dexmedetomidine

Acetaminophen, Dexmedetomidine

Post-procedure, similarity between Acetaminophen and Dexmedetomidine (picture above) vials led to accidental administration of the latter resulting in bradycardia and hypertension. After appropriate resuscitation and care, the patient was discharged home safely without any postoperative complications same day. Full disclosure of the event and the error was discussed with the patient and family. We also initiated a risk-management case and pharmacy was made aware of the error.

Submitted by
Kirolos Sami, MD and Sumit Singh, MD
UCLA, Greater Los Angeles VA


Pisacaina 2% – Lidocaina, Diluyenta
October 6, 2022

Pisacaina 2% - Lidocaina, Diluyenta

Pisacaina 2% – Lidocaina, Diluyenta

This 2 vials are commonly in the OR in Mexico.

Submitted by
Fernando Antonio Escudero Gutierrez, Anesthesiologist


Naloxone Hydrochloride Injection, Fentanyl Citrate Injection
September 7, 2022

Naloxone Hydrochloride Injection, Fentanyl Citrate Injection

Naloxone Hydrochloride Injection, Fentanyl Citrate Injection

Submitted by
Sara Jordan Hyland, PharmD
OhioHealth Grant Medical Center


Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection
June 3, 2022

Phenylephrine Hydrochloride Injection, Neostigmine Methylsulfate Injection

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

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

Ephedrine, Phenylephrine, Metoclopramide, Famotidine

Cefazolin, Flumazenil

Cefazolin, Flumazenil

Tranexamic Acid Injection (same medication labeled with multiple colors)

Tranexamic Acid Injection (same medication labeled with multiple colors)

Atropine Sulfate, Ondansetron, Dexmedetomidine (same medication labeled with multiple colors)

Atropine Sulfate, Ondansetron, Dexmedetomidine (same medication labeled with multiple colors)

Heparin Sodium Injection, Calcium Gluconate

Heparin Sodium Injection, Calcium Gluconate


Submitted by
Janette McVey, MD
University of Missouri Healthcare


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