National Alert Issued: Look-Alike Packaging May Cause Confusion between Neostigmine and Phenylephrine

March 24, 2015

The alert warns of potentially dangerous mix-ups between 2 relatively new presentations of older medications.

PRESS RELEASE

BETHESDA, MD—A National Alert for Serious Medication Errors has been issued by ASHP and the Institute for Safe Medication Practices (ISMP), warning of potentially dangerous mix-ups between two relatively new presentations of older medications, neostigmine injection and phenylephrine injection.

The products are manufactured by Eclat Pharmaceuticals as Bloxiverz (neostigmine) and Vazculep (phenylephrine). Bloxiverz is a chlolinesterase inhibitor indicated for the reversal of non-depolarizing neuromuscular blockade after surgery. Vazculep is a phenylephrine injection product approved for treatment of clinically important hypotension resulting primarily for vasodilation in the setting of anesthesia.

Healthcare practitioners have reported concerns about look-alike packaging of Bloxiverz 10 mg per 10 mL and Vazculep 50 mg per 5 mL. Similarities in the size, color, and design of the vials and outer cartons have resulted in storage mix-ups and at least five close calls in which the wrong product was used during sterile compounding. In each reported case, the error was identified during an independent check by a second person.

The alert provides recommendations to safeguard against mix-ups, including keeping supplies of the drugs widely separated in both long and short-term storage areas; alerting staff to the potential risk of confusion between the two drugs; barcode scanning of containers during inventory management and prior to dispensing; and diluting phenylephrine injection before administration.

Alerts are issued by ASHP and ISMP when a significant risk for serious or fatal errors is detected through ISMP’s National Medication Error Reporting Program (MERP). Alerts are distributed to healthcare practitioners and organizations through ISMP, ASHP, and the National Council on Medication Error Reporting and Prevention.

About ASHP

ASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s more than 40,000 members include pharmacists, student pharmacists and pharmacy technicians. For over 70 years, ASHP has been on the forefront of efforts to improve medication use and enhance patient safety. For more information about the wide array of ASHP activities and the many ways in which pharmacists advance healthcare, visit ASHP’s website, www.ashp.org, or its consumer website, www.safemedication.com.

About ISMP

The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit charitable organization that works closely with healthcare practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. ISMP represents more than 35 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. ISMP is a federally certified patient safety organization (PSO), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute. For more information on ISMP, or its medication safety alert newsletters and other tools for healthcare professionals and consumers, visit www.ismp.org or its consumer website, www.consumermedsafety.org.