Take Steps to Improve Safety When Loading High-Alert Meds Into Cabinets
A tragic med error will put the spotlight on preventing mishaps with high-alert meds in automated dispensing cabinets.
In this case, a nurse accidentally gave the paralyzing agent vecuronium...instead of the sedative Versed (midazolam)...to an UNintubated patient. The patient stopped breathing...and later died.
Unfortunately the weaknesses in the med use process that contributed to this error are common.