ISMP Alerts

Verapamil-Naloxone Look-Alike Vials

Verapamil-Naloxone

Imagine giving the opioid antagonist naloxone in error to someone with severe pain who is receiving morphine via patient controlled analgesia. That risk exists in hospitals that stock verapamil injection 5 mg per 2 mL vials manufactured by Exela Pharma Sciences and naloxone injection 0.4 mg per mL vials by West-Ward Pharmaceuticals. The vials use the same colors for the caps and container labels. The vials are also the same size and shape. Variation in the orientation of the printing on the labels may help differentiate them. Still, these vials look similar enough to create risk of mix-ups. We recommend hospitals purchase one or the other from a different manufacturer.

 

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