Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility
Timely dispensing and prompt removal. Pharmacy should practice just-in-time dispensing of neuromuscular products when possible to avoid unnecessary access to these products before use. When the drugs are no longer needed, place unused/partially used vials, bags, and syringes of neuromuscular blockers in a sequestered bin for return to the pharmacy. Unused patient-specific doses should be destroyed/discarded after the patient has been extubated or the drug has been discontinued.
Increase awareness. Educate staff about the risk of serious errors with these high-alert drugs. Provide staff with a list of both generic and brand names for all neuromuscular blockers available at your location, and include usual dosages and any special guidelines associated with preparation, distribution, administration, and monitoring. Also use the information above to assess your safety practices.
Verify competency. Establish a formal training program and competency verification process for practitioners involved in preparing, dispensing, and administering neuromuscular blockers (Santell, 2006). These drugs should only be administered by staff with experience in maintaining an adequate airway and respiratory support, and only in units where intubation and respiratory support can be provided.
This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, charitable nonprofit organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the June 16, 2016, issue of the ISMP Medication Safety Alert!
REFERENCES
Brown, L. B. (2014). Medication administration in the operating room: New standards and recommendations. AANA J, 82(6), 465–469.
Frazee, E. N., Personett, H. A., Bauer, S. R., Dzierba, A. L., Stollings, J. L., Ryder, L. P., … Daniels, C.E. (2015). Intensive care nurses’ knowledge about use of neuromuscular blocking agents in patients with respiratory failure. Am J Crit Care, 24(5), 431–439.
Graudins, L. V., Downey, G., Bui, T., & Dooley, M. J. (2015). Neuromuscular blocking agents: High-alert medications with ongoing risks of error. Anaesth Intensive Care, 43(2), 270–271.
Graudins, L. V., Downey, G., Bui, T., & Dooley, M. J. (2016). Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents. Jt Comm J Qual Patient Saf, 42(2), 86–91.
ISMP. (2016). 2016-2017 targeted medication safety best practices for hospitals. Retrieved from www.ismp.org/sc?id=417
ISMP Canada. (2014). Neuromuscular blocking agents: Sustaining packaging improvements over time. ISMP Canada Safety Bulletin, 14(7), 1–5.
Merry, A. F., Webster, C. S., Hannam, J., Mitchell, S. J., Henderson, R., Reid, P., … Short, T. G. (2011). Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: Prospective randomised clinical evaluation. BMJ, 343:d5543.
Parry, M., & Morris, S. (2007). Critical incident involving syringe labels. Anaesthesia, 62(1), 95–96.
Pennsylvania Patient Safety Authority. (2009). Neuromuscular blocking agents: Reducing associated wrong-drug errors. PA Patient Saf Advis, 6(4), 109–114.
Roberts, L. (2014). At least 15 children in Syria die in measles immunization campaign. Science. September 18, 2014.
Santell, J. P. (2006). Medication errors involving neuromuscular blocking agents. Jt Comm J Qual Patient Saf, 32(8), 417, 470–475.
Yang, Y., Rivera, A. J., Fortier, C. R., & Abernathy, J. H., 3rd. (2016). A human factors engineering study of the medication delivery process during an anesthetic: Self-filled syringes versus prefilled syringes. Anesthesiology, 124(4), 795–803.