Safety alert – cephazolin vials with red cap

We have been notified of a clinical incident whereby vecuronium was mistakenly administered to a patient instead of cephazolin. The anaesthetist raised concerns that the 2g cephazolin vials concerned have a red cap.
 
The college has contacted the manufacturer to point out that red is strongly associated with neuromuscular blocking agents¹ and the current presentation of the cephazolin vials presents a potential patient safety issue.
 ANZCA encourages manufacturers to move away from red caps on vials that are not neuromuscular blocking agents, particularly for vials routinely used in operating rooms.
 
While recognising that similar red caps are a system problem, vigilance is essential when clinicians are selecting drugs to administer and theatre staff are stocking drugs.

1. For example, see the Australian Commission on Safety and Quality in Health Care’s National Standard for User-applied Labelling of Injectable Medicines, Fluids and Lines.