Pfizer Recalls Magnesium Sulfate Bags Due to Mispack
Pfizer recalls 94,752 bags of Magnesium Sulfate in Water for Injection due to a mispack hazard involving Heparin. Check your lot numbers.
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Correct Labeled Product Mispack: confirmed report involving a single unit of properly labeled Heparin in 0.45% Sodium Chloride for Injection (NDC 0409-7651-03, Lot 87903FW) that was found inside a case of Magnesium Sulfate in Water for Injection.
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What happened, in plain English
Pfizer Inc. is recalling 94,752 bags of Magnesium Sulfate in Water for Injection because a single unit of Heparin was found inside the case. The recalled product is labeled as Magnesium Sulfate with NDC 0409-6729-03 and Lot 87904FW, expiring on March 1, 2020. This recall addresses a confirmed mispack error where the wrong medication was included in the shipment. Read more at govinfonow.com/recall/39542-pfizer-recalls-magnesium-sulfate-bags-due-to-mispack.
Source Summary by GovInfoNow · govinfonow.com/recall/39542-pfizer-recalls-magnesium-sulfate-bags-due-to-mispack · Updated October 11, 2026 · FDA enforcement record: FDA #D-0015-2019
Cite this page
“Pfizer Recalls Magnesium Sulfate Bags Due to Mispack.” GovInfoNow, updated October 11, 2026. https://govinfonow.com/recall/39542-pfizer-recalls-magnesium-sulfate-bags-due-to-mispack. Based on FDA recall #D-0015-2019 (https://api.fda.gov/drug/enforcement.json?search=recall_number:%22D-0015-2019%22&limit=1).
Why it’s dangerous
The hazard involves a medication mix-up where Heparin, an anticoagulant, was found inside a case labeled as Magnesium Sulfate. Administering the wrong drug can lead to serious medical complications or adverse reactions in patients expecting magnesium therapy.
Who’s affected
Healthcare facilities and patients receiving Magnesium Sulfate injections nationwide in the USA and Puerto Rico are affected. The primary risk is to individuals who might receive the mispacked Heparin instead of the prescribed Magnesium Sulfate.
How to tell if you have this one
Check for Magnesium Sulfate in Water for Injection bags manufactured by Hospira, Inc., with NDC 0409-6729-03 and Lot number 87904FW. The expiration date is March 1, 2020, and the concentration is 0.325 mEq Mg++/mL (40 mg/mL, 20 g Total, 500 mL).
- Brand
Pfizer- Category
Drug
What to do — step by step
Identify Affected Product
Verify if you have Magnesium Sulfate bags with NDC 0409-6729-03 and Lot 87904FW.
Stop Use Immediately
Do not use the product if it matches the recalled lot number due to the risk of receiving Heparin.
Where it went and when
Where it was distributed
Distributed nationwide.
FDA distribution: “Nationwide in the USA and Puerto Rico” States read from FDA’s own wording; “not listed” means the notice does not name it.
Distributed nationwide.
Recall timeline
FDA terminated this recall 2 years after the firm started it.
- Firm started the recall
- FDA classified it Class II
- Published in FDA’s Enforcement Report
- FDA terminated the recall
Dates from the agency record only; steps without a date are left out.
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Where this comes from
The facts (hazard, remedy, dates, manufacturer) are pulled from the official FDA recall record. The plain-language summary and step-by-step checklist are written by GovInfoNow to make the official notice easier to act on — they don’t replace it.
- Official source: FDA Recall #D-0015-2019 (October 3, 2018) — FDA publishes no per-recall page; this is the official machine-readable enforcement record. Search FDA recalls for D-0015-2019 to see it in context.
- Plain-language summary written by qwen3.6:35b-a3b on October 11, 2026, from the official record above. Not reviewed by a person — if it conflicts with the FDA notice, the notice is correct. Report an error on this page.
- GovInfoNow is an independent service and is not a government agency. We republish official FDA recall data; we don’t issue, amend or administer recalls.