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.
