MEDICATION ERRORS: Does the patient need a breather?

January 2006 
Volume 36  Number 1
Pages 14 - 14
  PDF Version Available!


Vials of the neuromuscular blocking agent pancuronium were misplaced in a bin holding vials of heparin flush solution. A nurse failed to notice the switch and flushed a patient's central venous catheter with pancuronium, which caused respiratory and cardiac arrest. The patient recovered after 10 hours of mechanical ventilation...

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