We recently received a complaint from a pharmacist and anesthesiologist about the labeling and packaging of various Baxter critical care drug products. The products look strikingly similar. Although product names appear in different colors, when these vials are partially turned, the same logo and black band with imprinted expiration date and lot number is seen. This might occur when vials are heaped together in a drug storage bin. Also, there is inconsistency in the way that small volume parenteral products are packaged by various manufacturers.
Some companies use a different color cap for each product.
Practitioners who rely in part on the cap color to differentiate drugs may easily be fooled into believing that the white cap represents one specific product. We are extremely concerned that the new packaging might lead to fatal medication errors if the product identification is missed. Such a scenario is not difficult to imagine. In 1995, an emergency room nurse, administering influenza vaccine to area residents during a community vaccination program, accidentally gave 7 individuals 0.5 mL of pancuronium injection, a neuromuscular blocker, instead of the vaccine. The small vials of vaccine were the same size, shape and color as pancuronium vials stored on the same shelf in the ER's refrigerator.