Mivacron Overview

Four weeks before the incident, the chief anesthesiologist decided it would be beneficial for his hospital to trial mivacron, a muscle depolarizing agent which results in temporary paralysis, because it had fewer cardiac side effects than other similar medications. The Pharmacy Committee agreed and the trial began in a limited basis. Mivacron was initially stored in the section of this small inpatient pharmacy dedicated to anesthesia. After tripping over the box several times, the pharmacy supervisor moved the box to the IV supply area.

     Flagyl, an antibiotic, is ordered on Saturday afternoon in response to a report that the diarrhea of an elderly male patient who has been hospitalized for the past six days with pneumonia had tested positive for clostridium difficile. The order is sent to the pharmacy. On the weekend evening shift in the pharmacy, one pharmacy technician scheduled to be on duty had called in. No additional help could be found. Up to this time, the flagyl, which is also known as metronidazole, was the only medication stored in a foil bag. The pharmacy is organized alphabetically, resulting in metronidazole and mivacron being stored next to each other.

     Mivacon and flagyl are both stored in a foil bag to reduce decay from sunlight. Neither has a label on the outside of the foil bag. Instead, the label is on the plastic IV bag inside the foil wrapping and a small window has been cut in the wrapping to allow product identification. When held upright, the product label slips below the window and is not visible. Mivacron is stored in a foil bag with a label that often slips below the wrapping, rendering it difficult to read. Because of previous adverse events/near misses, the manufacturer supplies labels to be applied to the bag to reduce substitution risk. The pharmacy technician thought the labels should be affixed upon dispensing and stored them in a drawer. Before the mivacron trial, flagyl was the only medication stored in a foil wrapper. The pharmacist and pharmacy technicians are unaware of the mivacron trial and believe flagyl is the only medication stored in a foil bag. The labels are not affixed.

     Nursing believes flagyl has to be hung in the foil bag although, in fact, the foil bag is really there to prolong the shelf life of the product by months and is unnecessary once the product is infusing. The pharmacist pulls the bag of mivacron erroneously, thinking it to be flagyl. The labeling window was not visible. He places a patient label and rate on it and sends it to the floor. The nurse hangs the bag, thinking it is flagyl. When she returns in 15 minutes, the patient is dead.

     All told, four patients inadvertently received the mivacron instead of the flagyl; three arrested and one died. The pharmacist and the pharmacy technician were fired and several nurses were suspended.