Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

ISMP Medication Safety Alert. 2005;10(19) 

In This Article

Unlabeled Syringes

  • Commercially prepared saline flush syringes were not available in the ED, so nurses prepared a supply of syringes each day from multiple-dose vials. Vecuronium had been prepared for a trauma patient in the ED, but it was not used. The syringe was not labeled and was inadvertently placed with the saline flush syringes. The syringe containing vecuronium was later used to flush the IV line of an alert 3-year-old child. The child became flaccid and respiratory efforts ceased. She was quickly intubated and ventilated, so permanent harm was averted.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.