National alert issued: Look-alike packaging may cause confusion between neostigmine and phenylephrine

The products are manufactured by Eclat Pharmaceuticals as Bloxiverz (neostigmine) and Vazculep (phenylephrine). Bloxiverz is a chlolinesterase inhibitor indicated for the reversal of non-depolarizing neuromuscular blockade after surgery. Vazculep is a phenylephrine injection product approved for treatment of clinically important hypotension resulting primarily for vasodilation in the setting of anesthesia.

Healthcare practitioners have reported concerns about look-alike packaging of Bloxiverz 10 mg per 10 mL and Vazculep 50 mg per 5 mL. Similarities in the size, color, and design of the vials and outer cartons have resulted in storage mix-ups and at least five close calls in which the wrong product was used during sterile compounding. In each reported case, the error was identified during an independent check by a second person.

The alert provides recommendations to safeguard against mix-ups, including keeping supplies of the drugs widely separated in both long and short-term storage areas; alerting staff to the potential risk of confusion between the two drugs; barcode scanning of containers during inventory management and prior to dispensing; and diluting phenylephrine injection before administration.

Alerts are issued by ASHP and ISMP when a significant risk for serious or fatal errors is detected through ISMP's National Medication Error Reporting Program (MERP). Alerts are distributed to healthcare practitioners and organizations through ISMP, ASHP, and the National Council on Medication Error Reporting and Prevention.