Table 3

 Incidents where patients were paralysed while awake

AetiologyNumber of incidents
A Syringe swaps
    Suxamethonium/fentanyl6
    Suxamethonium/pethidine1
    Suxamethonium/unspecified opioid1
    Suxamethonium/atropine1
    Suxamethonium/gentamycin1
    Suxamethonium/metoclopramide1
    Atracurium/midazolam2
    Muscle relaxant/reversal, postoperative2
    Antibiotic/thiopentone1
B Other
    Residual suxamethonium in injection port flushed into circulation with another drug given postoperatively2
    Atracurium by syringe pump, pre-induction1
    Suxamethonium mixed with fentanyl1
Total number20