April 2002: Safety Brief – Product Look-Alike WARNING
ISMP Canada has received two simultaneous reports of ‘near misses’ due to the similarities in packaging between (a) the AstraZeneca Xylocaine 4% sterile solution 5mL vial used for retrobulbar injection in ophthalmic surgery, and (b)the AstraZeneca Betaloc 5mg/5mL vial. Both product vials have white labels with orange colour coding, and both can be stock items in a Surgery Department. Because the generic names of these two products are close in the alphabet (lidocaine; metoprolol), they can end up being stored near to each other.Each of the reporting hospitals indicated that they had changed their Betaloc product to the Novartis ‘Lopresor’ brand of metoprolol, in order to differentiate the products.
