Back to the Basics: Preventing Administration of Neuromuscular Blocking Agents to Unventilated Patients


Neuromuscular blocking agents are high-alert medications because of their well-documented history of causing catastrophic injuries or death when used in error. These drugs paralyze the respiratory (and other) muscles during endotracheal intubation, during surgery, and in critical care to facilitate mechanical ventilation of critically ill patients. However, for decades, neuromuscular blockers have been inadvertently administered to both adult and pediatric patients who were not receiving proper ventilatory assistance, often by practitioners who thought they were administering a different drug. With yet another headline-grabbing fatal event involving inadvertent administration of a neuromuscular blocker in the news earlier this year, it is time to go back to the basics and take the necessary, crucial steps to reduce the risk of another tragic event.

Using examples of events that have been reported to the ISMP National Medication Errors Reporting Program (ISMP MERP), the webinar speakers will describe the key vulnerabilities with neuromuscular blockers that have led to errors and patient harm, including unsafe storage, look-alike labeling and packaging, drug name confusion, unsafe drug name searches, unlabeled syringes, unclear warnings, and others. The speakers will then define the best practices for safeguarding neuromuscular blockers and present targeted, national compliance data from associated surveys and self-assessment tools. Participants will be encouraged to reflect on their own level of compliance with these best practices and to make plans to implement any that are missing.

Intended Audience:

  • Quality and Risk Management Leaders

  • Nursing and Pharmacy Managers and Administrators 

  • Medication Safety and Patient Safety Officers

  • Nurses

  • Pharmacists

  • Anesthesia Providers

  • Clinical Educators

Learning Objectives:

Following completion of this activity, participants will be able to:

  1. Describe the underlying causes of events associated with administering a neuromuscular blocking agent to an unventilated patient.

  2. Identify best practices associated with safeguarding neuromuscular blocking agents.

  3. Recognize gaps in best practices that need to be adopted in their facilities.


Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon.), FASHP, President, ISMP


Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, President, ISMP

Judy Smetzer, BSN, RN, FISMP, Vice President, ISMP




CE Accreditation

No continuing education credits are available for this activity.


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