Medication errors are too frequent, especially in the hospital setting. One of the major causes I’ve found as someone who’s worked in the OR for the last 22 years is that many of the vials for very different medication will look exactly alike. For example, 10 mg (1 mL) of phenylephrine that we dilute down 1:100 (1 mL into 99 mL) so that 1 mL is 100 mcg. 1-2 mL is a typical dose given IV to a patient. This vial looks exactly like the vial of a commonly given steroid (dexamethasone) that is given undiluted (4mg/mL and we give 1-2 mL IV typically).
This error occurred at the facility I’m currently at just this year and is very easy to happen to even experienced providers.
If there were safety protocols in place, like for example only certain classes of medications can be or must be certain colors, this may cut out a significant potential for a serious safety event to occur.