United States of America. The names Narcan (naloxone) and Norcuron (vecuronium bromide) look alike when orders are handwritten and sound alike when orders are transmitted verbally. The ISMP has been alerted to four cases where patients in respiratory distress from opiate overdoses needed Narcan but inadvertently received vecuronium bromide, a neuromuscular blocker.

The ISMP makes the following recommendations to minimize the possibility of future errors:

. If possible, avoid unit stock of these drugs.

. Consider restricting the storage of Norcuron and other neuromuscular blocking agents to one of three places:

- the anaesthesiologist’s tray;

- the pharmacy (where the drug would be dispensed to areas outside the OR only after confirmation from the pharmacist that the patient was intubated and on a ventilator);

- or in a segregated, limited access area (not in an automated dispensing cabinet, in uncontrolled unit stocks or in emergency “crash cart” supplies where inexperienced personnel could obtain and misuse the drug).

Narcan should be ordered by weight in milligrams (mg) rather than by volume, such as the number of “amps” or vials. Including the strengths would have made it easier to differentiate Norcoron from Narcan in these cases, since Norcoron doses are typically higher than Narcan doses. Vecuronium bromide is available in 10 mg or 20 mg vials. Naloxone (Narcan) is available in 0.04 mg, 0.4 mg and 2 mg ampoules and 4 mg and 10 mg vials.

The USP is developing guidelines to prevent accidents with vecuronium and other neuromuscular antagonists based on the reports to the USP Medication Errors Reporting Program. One manufacturer (Marsam) packages generic vecuronium bromide in vials with vial caps, closures and labels that are prominently marked: “Warning: Paralyzing agent”. These warning statements may help to avoid an accident.

The ISMP recommends that hospitals dispense neuromuscular antagonists with auxiliary labels bearing this warning statement.

Reference: ISMP Medication Safety Alert! Vol. 3, Issue 20, 7 October 1998.