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.