Specifically:
* Imagine being fully conscious but being unable to move or breathe. Imagine the panic as you suffocate. That's how this patient died.
* The drug the nurse intended to give (Versed) was a sedative. The standard of care for sedation includes monitoring. There was no monitoring as there should have been. A simple pulse oximeter would have caught the error before it was fatal.
* Vercuronium is especially dangerous and thus tightly controlled. Only attending anesthesiologists and emergency medicine physicians give it independently. Residents give it under supervision. The only nurses who give it are CRNAs under direct supervision. The nurse had to go out of her way to get around restrictions designed to prevent her from giving it. The drug has warnings. And she had to mix it up herself, unlike every other time she gave Versed.