Wall of Shame

A page to warn about ampoules which are difficult to read, or which are easily confused with other drugs.

Recently found on the ward after a critical incident. As mentioned further down the page, the similar labelling is a safety feature.



Looking for an excuse not to pick up the kids from school? The Oxynorm 50mg for 10mg swap is guaranteed to get you out of hours of household chores. No Oxynorm? The 10mg for 2mg hydromorphone swap will achieve the same result.


Was that too obvious? Try this quick quiz. Which of these ampoules contains 50mg of oxycodone?






Here is a new candidate to put some excitement in your life. I saw LIN and wondered why Lincomycin was in the drug drawer. The font size of the manufacturer’s name is nearly 3x that of the drug.




I first saw this style of lignocaine ampoule when I looked for some saline to flush the drip before I did a labour epidural. On the bright side, it would speed the decision to proceed to Caesarean section. Since then it has made appearances in the operating theatre as well.


Here is a contender for worst ever label. The writing was so small, we had to photograph it and blow it up to see what the drug was.






We had a similar problem with granisetron a few years ago, but the manufacturer improved the label when they were notified.





I think these gentamicin ampoules are made by Nitin Lifesciences, but it is hard to tell because the writing is so small. I use the Magnifier App to read the writing on these ampoules.




Vasopressin by Samarth—clearly labelled in a 1.3 point font. What could possibly go wrong?





A couple from Aspen pharmaceuticals. Almost impossible to read, even in the best lighting.










Some more from Pfizer.

Lignocaine, midazolam and heparinised saline all very similarly labelled. Heparinised saline makes regular reappearances in our lignocaine drawer.



Pfizer’s reply was that this label was designed to improve safety as can be seen by the Pfizer label being rotated and the black highlighting on the lignocaine dose.

They also reminded me that secondary means of product identification do not absolve the anaesthetist from the legal responsibility to check the ampoule.


 The lignocaine 10% is markedly different from lignocaine 1%!

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