From the June 30, 1999 issue
- Caution! Morphine Sulfate Rapi-Ject syringes, manufactured
by Faulding, are available in 100 mg/4 mL (25 mg/mL) and
500 mg/10 mL (50 mg/mL) concentrations. The products have
dangerously similar packaging - the outer package is almost
identical in size, color, package design and layout (a photo
appears on our web site at www.ismp.org). Recently, a pharmacist
averted a serious error after she noticed that the volume
of drug in the syringe she had just assembled was more than
expected. She had accidentally opened a package containing
500 mg/10 mL instead of the intended amount, 100 mg/4 mL.
The pharmacy did not routinely stock the 500 mg/10 mL syringes,
but the wholesaler had sent the higher concentration in
error. Pharmacies should attempt to stock only one concentration
of this product. If both concentrations are needed, purchase
one from another manufacturer to reduce package similarity.
All narcotic IV admixture preparation needs an independent
double-check before dispensing, so that errors like the
one above will likely be detected.
25 mg/mL packaging
50 mg /mL packaging
- As more vaccines and combination products reach the market,
the potential for error is increasing. Several current vaccine
products have look-alike or ambiguous labeling/packaging.
For example, a notation "For Pediatric Use" is not prominently
placed on the package of pediatric diphtheria and tetanus
toxoids adsorbed purogenated vaccine, manufactured by Lederle
(Wyeth-Ayerst). While the drug name and the term "Purogenated"
appear bolded and in large print, the notation "For Pediatric
Use" appears unbolded and in small print.
Further, the notation "For Pediatric Use" is located between
the enlarged drug name and the enlarged term "Purogenated."
Incidentally, the package insert for this product notes,
"For Pediatric Use" in large, bold letters. Another problem
is the strikingly similar packaging/labeling on Merck's
PedvaxHIB (hemophilus b conjugate vaccine) and COMVAX (hemophilus
b conjugate vaccine and hepatitis B - recombinant).
Both vaccines are packaged in the same size and shape containers,
and the manufacturer's name and corporate dress is identical
(striped and shaded turquoise background with black printed
drug name and white printed label). The description of the
package contents is very similar; both begin with "haemophilus
b conjugate" on the first line and "meningococcal protein
conjugate" on the second line. On both packages, the third
line of product information, which distinguishes one from
the other, is not prominent or eye-catching, nor are the
products' brand names. While each vial top is a different
color (blue for PedvaxHIB and clear for Comvax), they are
not helpful in distinguishing the products, especially when
the vials remain in the carton. ISMP recently learned that
look-alike packaging for these two products has led to dozens
of children receiving the wrong vaccine. To minimize errors
with vaccine products, place auxiliary warning stickers
on the products as they enter drug inventory. In hospital
and retail pharmacy settings, build alerts into the pharmacy
computer system to warn pharmacists about the potential
for mix-ups. ISMP has asked Merck and Lederle to make package
and label changes that will present drug information more