September 2003: Look-Alike Product Alert
A hospital has reported a ‘near-miss’ where magnesium sulfate was almost administered instead of sodium chloride 0.9% as a flush solution. As shown in this issue of the ISMP Canada Safety Bulletin, both vials have identical orange-coloured plastic tops and similar hard plastic containers.Options to prevent substitution errors with these products include:
- Select vendors so that the products stocked by the hospital are not similar;
- Eliminate vials of magnesium sulfate from patient care areas where possible (e.g., dispense through a CIVA program); and
- Avoid using multi-dose bacteriostatic sodium chloride 0.9% for the purpose of a saline flush. Consider instead, the use of sodium chloride 0.9% injection in single-use vials or single-use syringes.
