Muscle Relaxant Administration Error
April 1, 2020

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“Another member of the anesthesia team began going through the anesthesia drug drawer and administered something to the patient.”
Case Context Provider Narrative Contributing Factors Lessons Learned
Case Context
Patient: 6 week old twin
Presenting diagnosis: pyloric stenosis
Planned procedure: pyloromyotomy
Past medical history: hypokalemia, corrected
Anesthetic plan: general anesthesia