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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Lidocaine, Dexmedetomidine
September 28, 2023

Premixed syringes of Lidocaine 1% and Dexmedetomidine 4 mcg/cc. Both are 5 cc volume syringes.

Lidocaine, Dexmedetomidine

Submitted by
Dean Monma, MD
Northwestern, Central DuPage Hospital

Protamine Sulfate, Glycopyrrolate
August 10, 2023

Protamine sulfate (10mg/ml) and Glycopyrrolate (0.2 mg/ml)

Protamine Sulfate, Glycopyrrolate

Submitted by
Benjamin M Sherman, MD, MBA, FASA
Kaiser Permanente, NW Permanente

Mepivicaine (Polocaine), Calcium Chloride
July 20, 2023

Mepivicaine hcl 2% and calcium chloride 10%

Mepivicaine (Polocaine), Calcium Chloride

Submitted by
Benjamin M Sherman, MD, MBA, FASA
Kaiser Permanente, NW Permanente

International Alert – Japan:
TXA, Hyperbaric Bupivacaine, Isobaric Bupivacaine | Mepivacaine, TXA | TXA, Levobupivacaine
July 1, 2023

From the left, TXA, hyperbaric bupivacaine, and isobaric bupivacaine. Although the colours are different, the shapes are quite similar. If one has colour vision deficiency, it would be the risk of drug error.

TXA, Hyperbaric Bupivacaine, Isobaric Bupivacaine

The left is mepivacaine, and the right is TXA. Same shape & same colour are high risk of drug error. If you swap these, it would be catastrophic.

Mepivacaine, TXA

TXA & levobupivacaine. Of note, we apply NRFit; thus, the syringe does not fit the vial inlet.

TXA, Levobupivacaine

NRFit, Syringe Does Not Fit the Vial Inlet

Submitted by
Yusuke Mazda, MD, PhD
Saitama Medical Center, Saitama Medical University
Japan

Calcium Gluconate, Sodium Chloride | Paracetamol, Metronidazole | Magnesium Sulphate, Water | Levobupivacaine (Chirocaine), Sodium Chloride | Bupivacaine, Sodium Chloride
June 29, 2023

Calcium gluconate & sodium chloride found in same box in an anaesthetic Room.

Calcium Gluconate, Sodium Chloride

IV paracetamol 1000mg & 500mg & IV metronidazole bottles.

Paracetamol, Metronidazole

Magnesium sulphate & water for injection blow fill ampoules.

Magnesium Sulphate, Water

Levobupivacaine & sodium chloride ampoules in same box in an anaesthetic room.

Levobupivacaine (Chirocaine), Sodium Chloride

Bupivacaine & sodium chloride blow fill ampoules found in same box in an anaesthetic room.

Bupivacaine, Sodium Chloride

Submitted by
Joanna Correa-West, PGDip, BSc (Hons)
Birmingham Women’s and Children’s NHS Trust UK

Succinylcholine Chloride, Rocuronium Bromide
April 7, 2023

Succinylcholine Chloride, Rocuronium Bromide

Submitted by
Stanley Thornton, MD

Tranexamic Acid, Chloroprocaine Hydrochloride | Phenylephrine Hydrochloride, Dexmedetomidine Hydrochloride
April 6, 2023

Dear APSF editors,

I would like to bring to your attention two drug Look-Alike at our institution.

The first one is with chloroprocaine 1% for spinal use and tranexemic acid 500mg both in a 5ml glass ampule. These two medications are used frequently in our obstetric OR. this is an important safety concern given the bad outcome associated with intrathecal administration of tranexemic acid.

Tranexamic Acid, Chloroprocaine Hydrochloride

The second one is with phenylephrine 10mg in 1ml vial and dexmedetomidine 200mcg in 2ml vial. Even the total volume of the vial are different, the relative size is similar.

Phenylephrine Hydrochloride, Dexmedetomidine Hydrochloride

Thank you for your important work.

Submitted by
Simon Robichaud, MD
Anesthesiogy Resident PGY-3
Université Laval
Québec, Québec, Canada

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