23/10/2025
Lee is a post- operative ICU patient who needed a scheduled dose of a common anti-nausea medication.
The nurse retrieved the medication from the Automated Dispensing Cabinet. Due to similar vial size, color, and placement in the drawer, the nurse accidentally selected a vial of a neuromuscular blocking agent instead of the anti-nausea drug.
Fortunately, a second safety check was being performed by a colleague, who immediately identified the dangerously incorrect medication before administration. The error was caught, and the patient was unharmed.
THE QUESTION FOR QUALITY PROFESSIONALS:
This near-miss proves one control failed, but another succeeded. What is the single most critical system-level intervention your quality team would implement or enforce to prevent this specific "look-alike vial" mix-up from reaching the patient?
A- Storage
B- Procedure
C- Technology
Share your strategies for a safer system! 👇
