Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport Paul MacDowell, PharmD, BCPS and Eloh McGee, PharmD | July 31, 2024

https://psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport In this WebM&M Case, a 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium. The commentary highlights the importance of “double checks” during medication administration and how both technologic approaches and human factors engineering principles can support safe medication administration practices.