Watch for Paralyzing Agents WithOUT Usual Warnings

Some rocuronium and vecuronium vial CAPS will be missing the words "paralyzing agent"...due to med shortages during COVID-19.

FDA is temporarily allowing blank caps...to help manufacturers quickly meet increased demand for ventilated patients.

All vials will still say "paralyzing agent" on their LABELS.

Use extra caution when handling these neuromuscular blockers...mix-ups could lead to serious harm and possibly death.

For instance, rocuronium vials have yellow caps...but so do some vials of metoprolol.

And vecuronium vials can have gray caps...but so can vials of gentamicin and labetalol.

Place a "WARNING: PARALYZING AGENT" label on blank rocuronium and vecuronium caps...to differentiate them from other meds with similar caps.

Continue to separate neuromuscular blockers from other meds.

For example, store them in lidded boxes in the pharmacy and lock-lidded compartments in automated dispensing cabinets...and add brightly colored warning labels to these compartments.

Position vials so that labels are visible whenever possible.

Always read labels fully...to help ensure the right med is dispensed. Don't default to visual cues, such as color and size, for identification...even if you've dispensed the med a hundred times.

Avoid overriding bar-code systems. The chance of an error increases each time a bar code is bypassed or a shortcut is used.

Get our technician tutorial, Dispensing Meds for Surgeries, to learn about more safety strategies for these high-alert meds.

Key References

  • ISMP Med Safety Alert! Acute Care 2020;25(11):1-4
  • www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-health-care-professionals-temporary-absence-warning-statement-vial-caps-two-neuromuscular (7-30-20)
  • www.ismp.org/news/ismp-issues-safety-recommendations-prevent-errors-neuromuscular-blockers (7-30-20)
  • www.ismp.org/resources/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility (7-30-20)
Hospital Pharmacy Technician's Letter. August 2020, No. 360822



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