Safety Brief

From the March 7, 2001 issue of MSA Acute Care Edition Newsletter

Anesthesia professionals have been hit hard by the nationwide shortage of anesthetics and muscle relaxants. Avoiding the pitfalls of using less desirable alternatives has not been easy. We recently wrote (February 7, 2001 issue) about a few serious errors that occurred when sufentanil was used as a replacement for fentanyl. Last week, we heard about a potentially serious situation due to the shortage of succinylcholine. A technician ordered a supply of 10 mL vials of QUELICIN (succinylcholine) directly from the manufacturer, Abbott Laboratories. The pharmacy expected to receive the usual concentration of 20 mg/mL, but instead received 10 mL vials of 100 mg/mL, a strength used less frequently in hospitals. Side by side, the 10 mL vials are slightly different in size, but the labels look very similar (see photo below). If the more concentrated strength had been dispensed to anesthesia unnoticed, serious patient harm could have resulted. The hospital is unsure if the technician simply ordered the drug by volume only (10 mL vials) or if the manufacturer just sent the only strength available. If non-pharmacists are ordering products, be sure they know and specify the drug's strength and vial size. Equally important, be sure to verify the medications when the shipment arrives before placing them into stock.