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Safety Briefs


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 clearly.
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