1. Cohen, Michael R. RPH, MS, ScD

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A pharmacist found a vial of succinylcholine in an automated dispensing cabinet bin that was supposed to hold vecuronium vials. Both drug vials were enclosed in ShrinkSafe ID sleeves, which fit over the vial and tighten around it when heated. The hospital used these ID sleeves to differentiate neuromuscular blocking agents, a class of high-alert drugs. However, using the ID sleeves on all neuromuscular blocking agents led to confusion of drugs within the class.


The clear ID sleeve lets the drug name show through, but adds vivid warnings about the drug's paralytic nature. According to the manufacturer, health care providers must remove the sleeve to use the drug, helping ensure that they read the warning.


Neuromuscular blocking agents have different storage requirements, rates of onset, duration, and hemodynamic effects. Reduce the potential for error by using ID sleeves selectively, eliminating or minimizing the variety of neuromuscular blockers stored in clinical areas, and storing them only in clinical areas where patients are mechanically ventilated.

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