Hazard Warning - Look-alike containers of NIMBEX (cisatracurium besylate) injection

From the August 8, 2001 issue of MSA Acute Care Edition Newsletter

This neuromuscular blocking agent is available in a 20 mg/10 mL (2 mg/mL) multiple dose vial as well as a 200 mg/20 mL (10 mg/mL) single dose vial meant for preparing infusions. The vials are distributed in individual cartons that are exactly the same size. Both use teal print for the drug name and black print for the strength (see photo on our web site). In the past three weeks, we received two error reports as well as one report about the potential for confusion. In one case, a patient experienced prolonged recovery after it was discovered that the 200 mg/20 mL concentration was used for a bolus injection. Abbott Laboratories told us that label enhancements are now underway. In the meantime, if Nimbex is available, communicate with all who may use this drug, including OR staff, pharmacists and pharmacy technicians. In addition, draw attention to the product strengths by circling the concentration on the carton labels.