AHRQ Patient Safety Network: Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.

AHRQ Patient Safety Network



Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.

ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19:1,4.

This newsletter article discusses an adverse drug event involving a patient who died after receiving a neuromuscular blocker instead of a seizure control agent. The preparation error was associated withincorrect labeling. Because neuromuscular blocking agents are considered high-alert medications, more robust administration processes should be employed to reduce the potential for mix-ups.

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