Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Publication Type: Patient Safety Alert
Single or Multiple Incident: Single
Date: 10/15/2019 12:00:00 AM
Country: South Korea
This alert describes a fatal medication error where a neuromuscular blocker used for general anesthesia or to support mechanical ventilation was given instead of an oral centrally acting muscle relaxant; the patient died of cardiac arrest. The neuromuscular blocker produces respiratory paralysis. The alert provides recommendations to prevent similar adverse events. Included are improvement practices made by the organization as well as best practices from external sources.

Additional Details

Medication/Gas/Fluid:
neuromuscular blocker, muscle relaxant
Medication/IV List:
neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)

Rules / Policies / Procedures
  1. Know the difference: Route of administration of muscle relaxant: - Centrally acting muscle relaxant: For muscle relaxation when muscle spasm or strain → Oral medication for the first prescription - Neuromuscular blocker: For an operation that needs mechanical ventilation or general anesthesia → Intravenous injection
  2. Use of neuromuscular blocker: It is recommended to use a patient monitoring system for continuous monitoring and essentially supply oxygen to the patient.

Adverse event, caused by wrong administration of neuromuscular blocker