Managing Risks

Mivacurium (Mivacron), instead of metronidazole, was accidentally administered to several patients at a large
hospital. Three patients went into respiratory arrest, and one died. A multidisciplinary team was assembled to
analyze the event and determine actions that could be taken to prevent similar errors from recurring. Here’s
what they found:
A technician pulled several bags of foil-wrapped IV items from the bulk IV storage area. At the time, it was
thought that metronidazole was the only medication in the pharmacy that was packaged in foil outer wraps.
However, the anesthesia department had ordered samples of mivacurium from a drug representative without
notifying the pharmacy. A shipment of sample products had been delivered to the pharmacy the previous day
and placed into stock without notice. The technician placed pharmacy-generated labels that said
“metronidazole” on the foil outer wrap of each bag. The pharmacist checked the bags and the computergenerated labels against the physician’s order. No one noticed that the foil-wrapped bags actually contained
mivacurium. The mivacurium was sent to the nursing unit mislabeled as metronidazole.
Many organizations treat near misses in the same way that they treat sentinel events, using error-reduction
tools such as root-cause analysis or failure mode and effects analysis in an effort to prevent future
occurrences.
Based on this case, what steps would you consider to find the root-cause of the problem? What
recommendations would you make to manage the risks going forward?