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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ISMP has received reports from several healthcare institutions that recently received cardboard cases labeled “Isoflurane USP 100 mL” by Piramal Critical Care (NDC 66794-017-10) (Figure 1) that actually contained bottles of Isoflurane, USP 100 mL labeled “for animal use only” by Covetrus (NDC 11695
B. Braun recently announced a new presentation of potassium chloride for injection concentrate (2 mEq/mL) in a 250 mL EXCEL container plastic bag with blue and red labeling, and a blocked medication port. The 250 mL product is a pharmacy bulk package and should only be used in a pharmacy admixture
On December 22, 2021, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for PAXLOVID, consisting of oral tablets of nirmatrelvir that are co-packaged with oral tablets of ritonavir (an FDA-approved antiretroviral agent). Indications Emergency use of Paxlovid is