Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.
Approach to Improving Safety
Setting of Care
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 with incorrect labeling. Because neuromuscular blocking agents are considered high-alert medications, more robust administration processes should be employed to reduce the potential for mix-ups.