Managing visits from pharmaceutical sales representatives.

Vol. 37 No. 5 • May 2012 • P&T® 261 mivacurium following a sales visit by a pharmaceutical representative. The carton of mivacurium was delivered to the pharmacy and was placed in stock next to metronidazole. Both products were packaged in foil overwraps. Before the error occurred, metronidazole had been the only foil-wrapped, premixed solution in the pharmacy; miva curium was not on the formulary. Neither the technician nor the pharmacist who prepared and dispensed the erroneous drug was aware that a trial carton of miva curium had been delivered to the pharmacy. Thus, they failed to notice that the foil-wrapped bags contained mivacurium, not metronidazole. At the time of the error, the drug name was not on the foil overwrap and was not easily visible through a clear plastic window. Thinking that the drug was lightsensitive, nurses who administered the drug did not remove the foil overwrap entirely and therefore also failed to notice the error.