Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility

Orders entered into wrong electronic health record

A medical resident electronically prescribed vecuronium for the wrong patient with a similar name, who was located on a medical unit. The correct patient was ventilated and in the ICU. The pharmacist and technician did not question the infusion for a medical unit patient. An independent double check was carried out by two nurses before administration, but neither nurse was aware that the patient required ventilation with this drug.

Knowledge deficit about drug action and required ventilation

An ED physician gave a verbal order for a trauma patient to receive vecuronium and midazolam, which were administered prior to intubation. He then mistakenly entered electronic orders for these medications into another patient’s record. An ED nurse administered the medications to the patient without recognizing that vecuronium would paralyze the respiratory muscles. After she left the room, the patient arrested. The ED team responded, but the patient could not be resuscitated.

Syringe swaps

Succinylcholine was inadvertently administered instead of fentaNYL prior to the induction of anesthesia (Parry & Morris, 2007). The anesthetist had drawn up both drugs into 2 mL syringes, and had applied a blank red and black label on the succinylcholine syringe and a manufacturer-supplied label to the fentaNYL syringe, which was also red and black—a label color in anesthesia reserved for neuromuscular blockers. The anesthetist picked up the succinylcholine syringe, believing it contained fentaNYL based on its position on the table.

A patient became unresponsive in the holding area after IV administration of cisatracurium instead of midazolam. The patient was ventilated and the surgery proceeded. Two additional syringe swaps involving cisatracurium outside the OR were reported (Santell, 2006; Graudins, Downey, Bui, & Dooley, 2016).

Reversal agent not available

Several practitioners have reported that reversal agents (i.e., neostigmine, sugammadex) for neuromuscular blockers have not been available when needed in the OR and elsewhere. One reporter said the reversal agents were in a locked cabinet and not accessible.

Residual drug in tubing

In a post-anesthesia care unit (PACU), a nurse administered a dose of HYDROmorphone through an IV line in the patient’s left arm. The IV line in the patient’s right arm was clamped, so the nurse opened the line and flushed it. About 2 minutes later, the patient stopped moving and breathing, and his oxygen saturation fell to 40%. Anesthesia was called, and the problem was thought to be caused by flushing the remaining rocuronium in the IV tubing into the patient. Neostigmine was administered for blockade reversal.

Dose or rate confusion

Mental mix-ups have led to numerous dosing errors. For example, rocuronium was infused at the rate intended for cisatracurium, and several patients received the wrong dose of rocuronium because the physician dosed it in mcg/kg/hour, not mcg/kg/minute.

Safe Practice Recommendations 

Serious adverse events continue to occur with neuromuscular blockers when they are used without adequate safeguards. Although the causes are varied, many of the most harmful or fatal errors involve the accidental administration of a neuromuscular blocker when another drug is intended. Thus, adherence to proper ordering, storage, selection, preparation, and administration is paramount. Neuromuscular blockers are also a focus of Best Practice 7 in the ISMP 2016-2017 Targeted Medication Safety Best Practices for Hospitals, which aims to promote safe storage of neuromuscular blockers (ISMP, 2016). To reduce the risk of harm from neuromuscular blockers, consider the following recommendations. The Primary Recommendations should be given the highest priority for action by hospitals and surgery centers. The Secondary Recommendations are also very important but address the common causes of medication errors that are not necessarily unique to neuromuscular blockers.