Paralyzed by Mistakes: Preventing Errors With Neuromuscular Blocking Agents

ISMP Medication Safety Alert. 2005;10(19) 

In This Article

Failure to Assure Ventilator Support

  • An ED physician ordered a neuromuscular blocking agent to sedate a combative patient. However, a nurse administered the drug too soon, before the patient could be intubated. The patient arrested and suffered permanent anoxic injury.

Neuromuscular blocking agents are considered high-alert drugs because misuse can lead to catastrophic injuries or death. These drugs should be given your highest attention, just as you've done with cancer chemotherapeutic agents. To reduce the risk of harm from neuromuscular blocking agents, consider the following recommendations.

Limit Access. When possible, dispense neuromuscular blocking agents from the pharmacy as prescribed for patients. Allow floor stock of these agents only in the OR, ED, and critical care units where patients can be properly ventilated and monitored.

Segregate Storage. When these agents must be available as floor stock, have pharmacy assemble the vials in a sealed box with warnings affixed as noted below. Sequester the boxes in both refrigerated and non-refrigerated locations.

Warning Labels. Affix fluorescent red labels that note: "Warning: Paralyzing Agent-Causes Respiratory Arrest" on each vial, syringe, bag, and storage box of neuromuscular blocking agents. (Incidentally, neuromuscular blocking agents were available as floor stock outside the OR in 80% of hospitals that responded to the 2004 ISMP Medication Safety Self Assessment. When available outside the OR, these drugs were not sequestered from other floor stock items or labeled with auxiliary warnings by 59% of respondents.)

Safeguard Storage in the Pharmacy. Sequester and affix warning labels to vials of neuromuscular blocking agents stocked in the pharmacy. Be sure they do not obscure the vial label in any way.

Manufacturer Warnings. Use brands of neuromuscular blockers that clearly differentiate the vials from other products via warnings on the package label, vial cap, and metal ferrule around the rubber stopper. (As of October 1, 2005, all manufacturers of these agents will be required to provide this cautionary labeling.)

Standardize Prescribing. Do not accept neuromuscular blocking agent orders for "use as needed for agitation." Establish order sets to prevent misinterpretation of handwritten orders. Include the need for ventilation support during and after administration, and a protocol that stipulates automatic discontinuation of these agents after extubation and removal from a ventilator. Never accept orders to "resume the same medications" upon patient transfer.

Computer Reminders. Build alerts in the pharmacy computer to verify the patient's location when neuromuscular blocking agents are entered. If the patient is not in a critical care unit, ED, OR, or invasive procedure area, question the order and verify ventilatory assistance before dispensing the drug. If possible, establish computerized crosschecking of the patient's location when entering neuromuscular blocking agents (and other drugs limited to administration on a specific unit). Cautionary messages should also appear on automated dispensing cabinet screens when applicable. A pop-up box that asks, "Is the patient being ventilated?" may also be helpful.

Redundancies. Before dispensing and administering neuromuscular blocking agents, require an independent double check of the drug against the actual order.

Supervision During Initial Administration. Require bedside attendance of a licensed practitioner who has experience with intubation and airway management during initial administration of a neuromuscular blocking agent.

Drug Verification. Implement point-of-care bar coding to verify drugs, doses, routes of administration, and patients before administration of medications.

Prompt Removal of Discontinued Products. Place vials, bags, and syringes of neuromuscular blocking agents in a sequestered bin for immediate pharmacy pick-up 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 blocking agents available at your location. Also use the information above to assess your safety practices.

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