Medication Errors
Michael R. Cohen MS, RPH

January 2011 
Volume 41  Number 1
Pages 16 - 16
  PDF Version Available!

The 1 mL vials of the potent vasoconstrictor vasopressin (20 units/mL) and the anticholinergic agent atropine sulfate (0.4 mg/mL), both from American Regent, look very similar. The colors of the labels and caps are nearly identical, as are the size and style of the font used in the printed drug information.An OR pharmacist noticed the similarities in the two vials while restocking a medication cart. Because both drugs could be used in the same clinical settings, hospitals should buy one of the drugs from a different manufacturer to help distinguish the two drugs, and store them in separate locations whenever possible. As always, read labels carefully before administering medications.A patient was prescribed chlorambucil, an oral antineoplastic agent, "one tablet BIW," which a pharmacist interpreted as "one tablet twice daily." What the prescriber meant was one tablet twice a week. The error was caught by a second pharmacist. (The person who reported this error didn't include the tablet

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