Naloxone Vials Look Too Much Like Verpamil, Leading To Medication Mistake Risk: ISMP

Health experts are warning doctors of potential mix-up dangers associated with two injection solutions that contain the same color caps, bottle shape, and label colors. 

The Institute for Safe Medication Practices (ISMP) issued a drug label warning on April 24, 2018, alerting hospitals and medical centers not to 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, because the vials look so similar that health care professionals could get them confused..

According to the warning, there is a strong possibility that medical professionals could mistake Exela Pharma Sciences’ verapamil injections, which is a calcium channel blocker used for treating mild to moderate high blood pressure, for West-Ward Pharmaceuticals’ naloxone injection, which is a hydrochloride solution used for the complete or partial reversal of opioid depression.

Naloxone is a generic drug that has been available for more than 40 years and is designed to counter overdoses of heroin and prescription opioids such as hydrocodone, oxycodone, codeine, and tramadol. The drug is considered safe among government health officials and has a low risk of serious side effects.

ISMP experts are warning hospitals and medical centers that accidental error in vial selection could cause serious adverse health consequences to patients who receive the wrong injection.

The vials use the same color purple for the caps and separately on the labels. The vials are the exact same size and shape with similar size font, looking nearly identical.

The ISMP encourages hospitals not to stock these specific injection solutions from these manufacturers, and to purchase one or the other from a different manufacturer.

Last month, the ISMP issued a similar warning that medications known as “investigational drugs” are not being adequately labeled, named or packaged, despite the fact that they are experimental and may carry higher risks of serious side effects and injuries.

Officials warned that one of the main issues at hand are that during the early phases of research, the drugs are identified with an abbreviation or a number that can be 25 characters long, and the only visual difference to tell drugs apart during clinical trials.

ISMP further warned that drug labeling confusion may continue even when a medication is finally named, because some labels on packing slips and boxes may get the generic name, while some labels on the medication continue to carry the identifier number, and that number could even change if the company is bought out or merges with another manufacturer during the drug’s testing period.