David U is President and CEO of ISMP Canada
Michael Hamilton is a Consultant Physician and Medication Safety Specialist for ISMP Canada
The deaths of 15 children who received measles vaccination in Syria were initially suspected to have been caused by tainted vaccine or sabotage, but now appear to have been the result of a tragic error. In a statement on the interim findings of an investigation released on September 28, 2014, the World Health Organization (WHO) reported that medical personnel most likely mixed the vaccine with the neuromuscular blocking agent atracurium, instead of the intended diluent. The atracurium had apparently been incorrectly added to vaccination packs in a district distribution centre. Like other neuromuscular blocking agents, atracurium paralyzes the muscles that are necessary for breathing and can only be used safely when mechanical ventilation is available to support breathing.
The fact that the potential for this type of tragedy had already been well-recognized makes the deaths of these innocent children all the more heartbreaking. Hundreds of errors with neuromuscular blocking agents have been reported around the world ...continue reading