FameCrawler

I think it is because the doses are packaged in very similar looking vials.  I used to work in pharmacy and we mixed them up all the time.  The worst was the lowest dose and the highest were both labeled with red colored ink about three shades different!  It kept us very nervous.  Accidental overdoses of Heparin has been happening for decades because of the labeling and the refusal of the drug companies to alter the vials.  They coudl make them different shapes and sizes for easier identification but that would cost a few pennies more.  Scum!  You cannot blame an overworked staff member who is in an emergency situation for grabbing the wrong vial.  Some of the blame goes to the lack of care shown by the manufacturer.

Well, I guess I can see the point of view that they make the labels for the two doses in similar colors and styles.  Currently, they look the same.  Yet I can remember when I started working that the IV flush concentration came with a bright yellow-green label.  Perhaps it was a different company ....

Yet I still hold that the hospital is the most at fault here.  It takes a few seconds to look at the medication when you pull it from the pyxis.  I am an ER nurse, and when things get more hectic than usual is when we have critical patients requiring critical meds.  Yet I still stop to look at meds before I give them.  Not trying to lay the blame all on one nurse - because there may be more to the story and the hospital may be just as guilty in allowing working conditions where this could happen.