Medication Look-Alike Alert Lidocaine and Rocuronium

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Alert Summary

This Medication Look-Alike Alert involves the potential risk of medication mix-up between lidocaine and rocuronium vials due to their similar packaging. Lidocaine, a local anesthetic, is known for its blue flip top packaging. Rocuronium, a paralyzing agent, traditionally had a yellow flip top, but certain vials packaged by Piramal now also feature a blue flip top, making the critical warning "paralyzing agent" less noticeable. This packaging similarity significantly raises the chances of medication errors. To mitigate this risk, it is recommended to always verify the medication name and concentration or strength when removing medications from inventory, including automated dispensing cabinets, and before their administration. Additional precautions, such as auxiliary labeling and separate storage, should be reinforced, and consideration should be given to sourcing alternative products if the risk of confusion persists due to similar packaging.

Date Issued: March 4, 2024

Situation - There is a potential for a medication mix-up due to similar product packaging for
lidocaine and rocuronium vials.

Background - Both lidocaine and rocuronium are commonly used in procedural areas.

  • Lidocaine, a local anesthetic, is packaged in a vial with a blue flip top
  • Rocuronium, a paralyzing agent, was previously packaged with a yellow flip top.

Rocuronium vials packaged by Piramal have a “blue flip top” and the words “paralyzing agent” are less visible as compared to the yellow flip tops.

Assessment - The similarity of the product packaging for lidocaine and rocuronium vials (packaged by Pirmamal) increases the potential for a medication mix-up and medication error.

Recommendation -

  1. The medication name and concentration or strength must always be validated when a medication is removed from inventory (to include automated dispensing cabinets) and prior to administration of a medication.
  2. Ensure all safeguards are in place (auxiliary labeling, storage, etc.) and consider purchasing alternative products if concern remains over similar packaging
Edeli Kinsala
Edeli Kinsala, RN, BSN, MBA, Vice President of Clinical Services

With a nursing career that spans almost four decades, Edeli Kinsala brings a wealth of experience to FlexCare. Starting her career in med/surg, telemetry, and trauma ICU, Edeli has held a range of positions, such as Director of Nursing, Chief Clinical Officer, and CEO, to name a few. Her exposure to various healthcare settings – acute care, long-term acute care, skilled nursing, drug/alcohol rehab, psychiatric/behavioral health, and travel staffing – enables her to deeply understand the needs and challenges of nurses and clinicians in different environments. Above all, Edeli's philosophy of caring for people and doing the right thing aligns perfectly with FlexCare's core values.