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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

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

Adverse event, caused by wrong administration of neuromuscular blocker