Michael R. Cohen, RPh, MS, FASHP
On Dec. 26, 2017, a nurse at Vanderbilt University Medical Center opened an automated dispensing cabinet (ADC) seeking a sedative for a patient with a cerebral hematoma about to undergo a PET scan. Rather than taking out 2 mg of Versed (midazolam, Roche) to treat the patient’s anxiety, as ordered, she mistakenly selected vecuronium, a neuromuscular blocking agent (NMBA). The patient subsequently received a lethal dose of the paralyzing