Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

ISMP Medication Safety Alert. 2005;10(19) 

In This Article

Look-Alike Packaging and Labeling

  • Nurses mistakenly reconstituted measles and BCG vaccines with pancuronium and administered the vaccines to healthy infants. One infant died after experiencing seizures and respiratory arrest. The pancuronium vial looked very similar to a vial of the correct diluent, sodium chloride injection.

  • An ED nurse administered pancuronium instead of influenza vaccine to several patients. The vials were the same size, and the labels were quite similar. The look-alike vials had been stored next to each other in the refrigerator. The patients experienced dyspnea and respiratory depression but, fortunately, sustained no permanent injuries.

  • Vials of pancuronium were misplaced in a bin holding vials of heparin flush solution. An ICU nurse failed to notice the mistake and flushed a patient's central line with the neuromuscular blocking agent. The patient arrested after the injection but fortunately recovered after 10 hours on a ventilator.

  • An adult patient received cisatracurium intended for a ventilated infant. The cisatracurium infusion had been delivered by accident to a medical unit along with three bags of antibiotics. A nurse had verified that the first three bags in the stacked pile of piggybacks were the prescribed antibiotics, but she was interrupted before checking the fourth bag, which contained cisatracurium. When she returned to the medication room, the nurse glanced at the yellow label, similar to the other labels on the antibiotics, and administered the neuromuscular blocking agent, believing it was an antibiotic. The patient experienced a respiratory arrest and required ventilation for a few hours.

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