Muscle Relaxant Administration Error

“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