Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

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.

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