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December 2002
Atracurium administered to SEVEN infants as opposed to Hepatitis B vaccine. Within 30 minutes, the infants experienced respiratory arrest. Five recovered, one critical at time of publication and one died.
ISMP Medication Safety Alert, Vol 7, Issue 25


October 1998
A verbal order for ?p Narcan?interpreted as ?p Norcuron? The wrong drug was administered to a patient who immediately stopped breathing. The patient was successfully resuscitated.

In a similar incident, a physician wrote an order for ?an 1 amp IV? ? nurse confused Narcan with Norcuron (vecuronium), proceeded to remove vecuronium from an automated cabinet, and administered it to the patient. The patient went into cardiac and respiratory arrest, was intubated and resuscitated, then transferred to ICU.
ISMP Medication Safety Alert, Vol 3, Issue 20


October 1996
Pancuronium administered to SEVEN outpatients during a routine influenza vaccination program. Vials of vaccine were the same size, shape and color and stored in the ER refrigerator next to the pancuronium.

14 patients presented with hypotonia, cyanosis, and dyspnea five minutes following immunization with Measles vaccine. One patient died. Succinylcholine and pancuronium found stored with vaccine. Other similar reports.
ISMP Medication Safety Alert, Vol 1, Issue 21


June 1996
ER physician treating combative patient ordered vecuronium without assuring the patient was appropriately ventilated. The patient received the drug without being intubated, and developed respiratory arrest.
ISMP Medication Safety Alert, Vol 1, Issue 11


Others?
Anesthesiologist administers vecuronium instead of intended potassium chloride during open-heart procedure. Same blue label color, size and shape.

Pancuronium vial misplaced into heparin flush drawer 孌 administered to a patient instead of heparin. Patient recovered after 10 hours on a respirator.
USP Quality Review 楢ruary 2000 No.72
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