Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
The Case
A 19-month-old boy was found unresponsive and not breathing by a parent; 911 was called and the patient was found to be in cardiopulmonary arrest with no respiratory effort. Comprehensive resuscitation efforts were carried out during and after transport to the closest emergency department (ED). Return of spontaneous circulation (ROSC) was noted after 60 minutes of resuscitation. Arrangement was made for transfer to a tertiary medical center via critical care transport. During transport, the patient was on mechanical ventilation and receiving fluids and vasopressors by intravenous infusion. The clinician(s) noted ventilator desynchrony and decided to initiate neuromuscular blockade. They opened an emergency medication kit and quickly retrieved a vial from a plastic bag labeled “intubation medications” (Figure 1). A vial, presumed to contain rocuronium, was opened and the medication was administered, without the intended paralytic effect. An open vial of flumazenil was then found on the gurney, confirming that this benzodiazepine antagonist had been administered instead of a paralytic agent. The clinician promptly corrected the error by administering the appropriate dose of rocuronium. No adverse reaction was noted due to administration of flumazenil in this context. The patient was successfully transferred to the receiving hospital for further care.
Figure 1. Example of Emergency Medication Kit

Root cause analysis revealed that the vial of flumazenil had been incorrectly placed in the “intubation medications” portion of the medication kit. Several copies of the same kit were opened following the event, and the spatial arrangement of items varied across kits. A visual reference existed to assist in preparing these kits; however, the images printed on paper did not clearly display the intended contents of the intubation medication bag (Figure 2). In response to this event, a new reference kit was created with clearer labeling and separation of individual drugs within the “intubation medications” bag (although drug shortages mandated inclusion of two different rocuronium products, which may still cause confusion) (Figure 3).
Figure 2. Example Preparation Reference (Standard)

Figure 3. Example Preparation Reference (Improved)

The Commentary
By Paul MacDowell, PharmD, BCPS, and Eloh McGee, PharmD
A 19-month-old boy in cardiopulmonary arrest was resuscitated and transported to a tertiary medical center via critical care transport. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead they unintentionally administered flumazenil (a benzodiazepine antagonist). Although this error was recognized and corrective action taken immediately, the case highlights multiple opportunities to collaborate and improve medication system design and workflow. Addressing these issues may enhance safe medication use and transport processes.
In this instance, the intended medication was rocuronium, which is considered a high alert medication by the Institute for Safe Medication Practices (ISMP).1 A medication is designated as “high-alert” due to elevated risk of patient harm when administered in error. The standard workflow within the transport team was to obtain a visual double check from another transport nurse. A visual double check would entail review to verify the correct medication, strength, and dose prepared. Unfortunately, in this instance, a double check was overlooked due to the multiple distractions during the complex post-resuscitation phase of this patient’s care. Other clinical care activities occurring concurrently included administration of fluid and vasopressors, as well as management of the ventilator. A recent review of studies on the impact of double check systems found that such processes may detect up to 95% of errors, with appropriate implementation.2 However, error detection rates were lower in some settings, where time constraints, task urgency, and staff resistance affected adherence. An earlier review highlighted practical problems associated with correct performance of double checking, including staff shortages, emergency situations, diversion of staff effort, and deference to authority.
In most hospitals, emergency medication kits are prepared by pharmacy technicians and checked by pharmacists using an RFID (radio frequency identification) platform. Using this technology while preparing medication kits can improve the efficiency and accuracy of preparation;3 however, this technology comes with limitations. Each medication unit (vial, syringe, or ampule) has an attached RFID tag that provides its identity and other information such as lot number, expiration date, and National Drug Code (NDC) number. The tagged items are arranged together as intended for the final kit. The kit bag itself contains an RFID tag identifying the intended contents of the kit. When all items are placed into an RFID reader, the count and identity of each item is compared to the expected kit contents. Items that are missing or unexpected, based on predetermined kit design, are flagged for further review. An RFID reader can identify the presence of each item as denoted by the tag, but it cannot identify the location of each item within the kit.
A typical emergency medication kit may contain approximately 20 different medications, multiple subunits containing small, labeled plastic bags, and various pockets and compartments (Figure 1). The compact nature of the bag used in a transport environment, and the variety of medications required, lead to storage challenges. In this case, the flumazenil vial was in a bag labeled “intubation medication,” even though flumazenil is not used during intubation. The physical appearance of injectable rocuronium may also have contributed to operator error. Some pharmacies provide prefilled syringes of rocuronium to transport teams, whereas others provide vials and instruct clinicians to use a needle and syringe to withdraw the medication from the vial. Prior instances have been reported where the similar appearance of vials of flumazenil and neuromuscular blocking agents contributed to administration errors.4 Human factors engineering principles support the concept that enhanced product design, such pre-drawn and pre-labeled syringes, may help prevent errors.5 Ready-to-use syringes are also endorsed by ISMP and anesthesia organizations.4 Unfortunately, due to the frequency of supply chain challenges and drug shortages, it is often necessary for pharmacies to change drug presentations, such as from vial to syringe, despite the confusion that may result.
Approaches to Improving Safety
The use of RFID technology may help to ensure that all the intended medications are contained in an emergency kit; however, the intended physical arrangement of the items largely relies on human judgment and decision-making. Thus, low-tech strategies must be considered, such as ensuring consistent placement of items in a multi-section container by appropriately labeling each section to match the item being placed within.
Preparing a medication kit, as with any manual process, benefits from clear training materials and references available in the work area, as well as ready access to all necessary materials in the expected locations. Random audits of completed kits may be added to ensure that kits are prepared as intended. Individuals preparing kits may have valuable ideas for improving accuracy and efficiency and should be engaged regularly for suggestions.
Additional layers of safety may be provided through “double check” practices during medication administration. As the ISMP has noted, effective double checks must be performed independently by a second person checking each component of the work process, and they “do not prevent errors, they simply catch them.” Consistent double check practices require clear supporting policy and training, and they remain “a poor substitute for system improvements that will actually help prevent errors.”2
Human factors engineering should be considered when designing and maintaining medication kits. Placement of items should be based on the frequency of use and safety principles. Clinician engagement in the design is crucial for success. Improved design incorporating human factors has previously been shown to improve medication retrieval times and reduce wasted actions in the context of code carts.6 Significant substitutions, such as change in concentration or change in format, should be shared with clinicians to reduce stress and confusion during emergencies. Another consideration is to regularly re-evaluate the contents of the kit, as usage of an item may change over time with clinical practice. Extraneous contents may add to the burden of quickly identifying needed items and may lead to expired and wasted products. Efforts spent to improve kit usability and design may lead to meaningful improvements to patient safety.
Take-Home Points
- Double checks during medication administration have value with judicious use and appropriate supports.
- Technology may be helpful to check for the presence of a given medication within a kit; however, review processes must exist to evaluate and verify spatial placement.
- Human factors engineering principles should be considered when designing kits and should be considered in an ongoing review process.
Paul MacDowell, PharmD, BCPS
Medication Safety Officer
Department of Pharmacy
UC Davis Health
pmacdowell@ucdavis.edu
Eloh McGee, PharmD
Resident Pharmacist
Department of Pharmacy
UC Davis Health
ennjikammcgee@ucdavis.edu
References
- ISMP List of High-Alert Medications in Acute Care Settings. Horsham, PA; Institute for Safe Medication Practices: 2024. Accessed July 26, 2024. [Available at]
- Independent double checks: undervalued and misused. ISMP Medication Safety Alert! June 13, 2013;18:1-4. Accessed July 18, 2024. [Available at]
- Rolko E, Chan T. Implementation of radio frequency identification for medication tray management. Can J Hosp Pharm. 2015 Sep-Oct;68(5):412-416. [Free full text]
- Grissinger M. Paralyzed by mistakes - reassess the safety of neuromuscular blockers in your facility. P T. 2019;44(3):91-107. [Free full text]
- Russ AL, Fairbanks RJ, Karsh BT, et al. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013;22(10):802-808. [Free full text]
- Rousek JB, Hallbeck MS. Improving medication management through the redesign of the hospital code cart medication drawer. Hum Factors. 2011;53(6):626-636. [Available at]