Danger! Paralytic Drugs!

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Insulin is double checked everywhere I've worked. But paralytics aren't? Are we nuts? My nursing career began in the 1980's, I'm retired now, but in all those years, one career ending error I've heard of consistently is med errors involving paralytics. I doubt accurate stats exist on the topic, but considering the danger to the patient and the horror of a single error ending a hard earned career, shouldn't we consider double checking this class of drugs? Paul Millard, RN, CEN, Etc, retired

[JKL33]

If you are referring to the RV situation, that didn't happen because something wasn't double-checked, it happened because something wasn't single-checked. Might as well have been a bowl of pills at a party.

[chare]

On 3/26/2022 at 12:22 PM, dthfytr said:

Insulin is double checked everywhere I've worked. But paralytics aren't? Are we nuts? My nursing career began in the 1980's, I'm retired now, but in all those years, one career ending error I've heard of consistently is med errors involving paralytics. ...

Aside from the current case in TN, which has been widely discussed here, I've not heard of another case, career ending or not, involving paralytic agents being administered to non-intubated patients that weren't being intubated.  Perhaps you would post links to the board action for these "career ending error" you're referencing.

On 3/26/2022 at 12:22 PM, dthfytr said:

... I doubt accurate stats exist on the topic, but considering the danger to the patient and the horror of a single error ending a hard earned career, shouldn't we consider double checking this class of drugs? Paul Millard, RN, CEN, Etc, retired

All paralytics, both bolus dosing and infusions, have required a double-check at every facility in which I have worked; and I would be surprised if this wasn't a requirement at the facility in question.  And this is for patients either undergoing RSI and patients that are intubated and ventilated.  However, as @JKL33 mentioned, this didn't occur as result of not completing a double-check of a paralytic agent.  It occurred because the first check wasn't done.  

[Mommavik, ADN]

I've never worked with paralytic drugs, so I'm not qualified to give an opinion as to the correctness of the OP's  post. However, I do agree that the mistake currently being discussed is one of not even looking at the name on the vial, not one of not double checking. I agree, though, that double checking,  could very well have prevented this tragedy. The problem with that is that she didn't get that she was removing a paralytic, even though it stated on the top and label of the vial that it was a paralytic. So she would not have don't a double check anyway. 

[offlabel]

Double checking a med has more to do with the dose than verifying the drug. If verifying the correct drug being given was requiring a 2 RN check, the list of double check drugs would be endless. The number of look a like vials is ridiculous. You'd have to double check that your giving ondansetron and not a stroke/MI inducing 10mg dose of phenylepherine just for starters...plenty more than that.