The Problem…

Look-alike drug names and packages increase the risk of unintended interchanges of drugs that can result in serious complications, even death. Hard to read or confusing labeling can also contribute to errors. Drug names appearing on labeling may be in small print. Two vials that appear to be virtually identical (except for the drug name) may contain vastly different drugs. If one of those vials contains a high-alert medication, the consequence of confusion could be tragic.

A Chief Anesthesiologist of a major medical institution describes his experience…

Inside were two vials, side by side. Both had yellow labels. Both had yellow caps. One was a paralyzing agent, which I had correctly administered to keep the patient still during the operation. The other was the reversal agent, which I needed next. "I grabbed the wrong one…I used the wrong drug."…

…He talked to his five partners, whose reaction unnerved him. "Four of the five of them said, 'You know, I've done the same thing,' " he said. "One of them said, 'I did the same thing last week.'”

Fortunately, the physicians associated in these cases recognized the error made and quickly remedied the situation by correctly infusing the reversal agent. However, many reported cases have resulted in serious sequelae, even death.

To read about other reported errors, click here.