Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

ISMP Medication Safety Alert. 2005;10(19) 

In This Article

Problem

Neuromuscular blocking agents have been inadvertently administered to patients who were not receiving proper ventilator assistance. Because the respiratory muscles were paralyzed, some patients have died or sustained serious, permanent injuries. In fact, the USP-ISMP Medication Errors Reporting Program has received well over than 50 reports concerning misuse of these agents over the past several years. Unfortunately, the true incidence of injuries from accidental administration of neuromuscular blocking agents is likely much higher than reflected by error reports.

While some errors have occurred in the operating room (OR), most have taken place outside this setting, in emergency departments (EDs), interventional radiology departments, intensive care units (ICUs), and other medical, surgical, and psychiatric units. Many errors can be attributed to one or more common root causes. Consider the following examples.

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