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 computer-generated 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.

When the nurses received the bags, they noted the pharmacy label for metronidazole on the outer foil wrap. They verified the drug name on the pharmacy label with the transcribed order on the patient's MAR. The medication was administered IV to four patients, still packaged in the foil outer wrap. All four patients went into respiratory arrest and one died several days later as a result of the error. The incident resulted in the termination of a pharmacist and a pharmacy technician and the suspension of several nurses.

discussion what went wrong in the scenario you have been assigned. Include in your initial discussion what steps might the healthcare organization take to prevent future instances, and what policies/procedures should be implemented based on this analysis.