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From the Oct. 22,1997 Issue

Safety Brief:

Hospitals using American Regent's sodium chloride injection 0.9% in 10 mL single dose (preservative-free) vials need to know that the company's 10% calcium gluconate 10 mL single dose vials are styled nearly identically. Both have green and white labels with black print and angled stripes in the lower right corner. The pharmacist who reported this told us her hospital is now purchasing a different brand of calcium gluconate in order to reduce the risk of a mix-up. We also heard from another pharmacist about the potential for confusing the company's vials of caffeine and sodium benzoate (500 mg/2 mL) with hydralazine 20 mg/mL vials. Both are contained in tiny 2 mL vials, have blue and white labels with black print, and blue vial caps. While no accidents occurred in either case, the potential certainly exists with either pair, especially if they get mixed up in storage, which is what happened in a hospital's satellite pharmacy with the hydralazine and caffeine/sodium benzoate vials. Action is warranted if your institution stocks either of these pairs. Don't put the situation to rest simply by relying on people to read labels. People may believe that they have read the label, but other factors beyond their control may confound them. ISMP has contacted the company to suggest packaging improvements.

Picture of Calcium Gluconate vial alongside Sodium Chloride vial

Picture of American Regents Caffeine and Sodium benzoate inj. vial alongside Hydralazine inj. vial

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