Pharmacy Services

Magnesium Sulfate and Potassium Phosphate - Potential for Error

August 6, 2009

Pharmacists are concerned about the potential for mix-up between American Regent brand potassium phosphates injection 50 mL vials and Hospira brand 50% magnesium sulfate (see picture).  The two products both have orange colored caps, are similar in size, and are used in a similar setting.

Recommendations for preventing medication errors include the following:

  • Encourage staff to read drug labels prior to compounding any intravenous admixtures requiring either of these agents.
  • Store the solutions in separate areas.

vials

Updated
August 6, 2009; University of Utah, Drug Information Service. Copyright 2009, Drug Information Service, University of Utah, Salt Lake City, UT.