Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

Drug Administration After Extubation

• A ventilated ICU patient was receiving vecuronium and a potassium chloride infusion. After the patient was extubated, vecuronium was discontinued. An infusion bag containing vecuronium remained in the room and was mistaken as a potassium chloride infusion. Soon after the medication was started, the patient arrested, requiring intubation and ventilation for 6 hours.

ISMP Medication Safety Alert. 2005;10(19) © 2005 Institute for Safe Medication Practices