IwAR0FcyaqcxIyduap4c8CxBmSs9I010H1cYr9ZAqjUdbz9MX1Ay8LxUGxCUM Short version: RN accidentally obtained and gave someone Vecuronium instead of Versed, left them unmonitored, resulting in death. Lessons Learned: 1) Although the nurse is definitely to blame for the failure, they failed within the system. Everything from the availability of Vecuronium to the 5Rs to post-administrative monitoring failed here. 2. Non-system factors: reading between the lines, the nurse was working in an ill-defined role, without adequate familiarity or training, and with an orientee. That's a significant cognitive workload, made worse by the fact that they were talking to one another during the issue and draw. Reconstitution also should have been a warning sign, but that goes to familiarity. 3. Profound overrreliance on software. Your thoughts?