Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

ISMP Medication Safety Alert. 2005;10(19) 

In This Article

Unsafe Storage

  • Atracurium was administered subcutaneously instead of hepatitis B vaccine to seven infants. The infants developed respiratory distress within 30 minutes. Five infants recovered, one sustained permanent injury, and another died. Neuromuscular blocking agents had never been available as floor stock in the nursery. For convenience, an anesthesiologist from a nearby OR had placed the vial of atracurium in the unit refrigerator near vaccine vials of similar appearance.

  • In a pediatric ICU, a respiratory therapist obtained what he thought was a sterile water vial to prepare a nebulizer treatment. As he was piercing the stopper, he fortunately noticed that he had accidentally grabbed a vial of atracurium that someone had inadvertently returned to a respiratory box in the refrigerator. The atracurium and sterile water vials both had similar purple color accents.

  • Unknown to pharmacy, an anesthesiologist had ordered trial supplies of mivacurium from a drug representative. When the product was delivered to the pharmacy, it was stocked next to look-alike bags of metronidazole. Both solutions were encased in foil wrappers. Believing metronidazole was the only product in foil wrappers in the pharmacy, a technician labeled several mivacurium bags as metronidazole. The pharmacist missed the mistake and four patients received mivacurium instead of metronidazole; all experienced respiratory arrest. One patient died, another was seriously injured, and two recovered.

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