News Release

ISMP Issues Safety Recommendations to Prevent Errors with Neuromuscular Blockers

Newsletter Article Addresses Lessons from Tragic Error  

A tragic medication error involving a neuromuscular blocker inspired the Institute for Safe Medication Practices (ISMP) to share lessons learned from the fatal event as well as prevention strategies in a recent newsletter article so that other healthcare providers can avoid similar tragedies in the future.

The cover article in this week’s ISMP Medication Safety Alert!® Acute Care newsletter describes the accidental administration of a neuromuscular blocker to an unventilated patient by a practitioner who thought they were administering a different drug. ISMP has observed similar system vulnerabilities in other hospitals, and they are frequently at the root of errors reported to the ISMP National Medication Errors Reporting Program (ISMP MERP). ISMP is urging healthcare providers to implement the following safe practice recommendations regarding neuromuscular blockers:

  • Establish a standard procedure for sedation prior to radiology procedures due to claustrophobia.

  • Include medications used for moderate sedation on the high-alert medication list.

  • Eliminate storage of neuromuscular blockers in areas where they are not routinely needed.

  • Place auxiliary labels on all storage locations that contain neuromuscular blockers with a clear warning about respiratory paralysis/need for ventilation.

  • Display an interactive warning on ADC screens that interrupts all attempts to remove a neuromuscular blocker via a patient’s profile or override.

  • Clarify hospital override policies and limit permitted use to emergency or urgent situations.

  • Avoid unjustifiable ADC overrides by limiting overrides to a handful of medications and configuring them by medication, user, and cabinet.

  • Require a witness prior to withdrawal of certain designated medications on an override.                                                                             

  • Monitor ADC overrides daily to review appropriateness and follow up on those that do not have corresponding medication orders.

  • Prior to administration, verify each medication via barcode scanning to ensure accuracy.

  • Require patient monitoring for IV sedation and specify parameters in hospital procedures or guidelines, including use of pulse oximetry and evaluation of adequate ventilation.

  • Avoid reconstituting medications in flush syringes, as happened in the case, since it results in a syringe mislabeled as 0.9% sodium chloride that actually contains medication.

  • Avoid distractions and talking at the ADC while searching for and withdrawing medications.

  • Teach practitioners to access medications from ADCs in profile mode where possible, understand the safety risks involved in an override, and how to search by either brand or generic name.

  • Adopt a Just Culture that removes any severity/outcome bias when judging behaviors of individuals involved in harmful patient care errors.

ISMP also is calling upon ADC vendors to increase the number of drug name letters required when searching non-profiled cabinets and during overrides and alert users to the fact that both brand and generic drug names may be displayed and searched, to avoid confusion. Manufacturers and regulatory-setting agencies should consider improvements to neuromuscular blocker container labeling, including adding the statement “WARNING: Paralyzing Agent” in bold red font to the carton and container label principal display panel.

Click here to access the full ISMP newsletter article with more details. ISMP provides additional strategies for safe prescribing, storage, selection, preparation, and administration of neuromuscular blockers in a June 16, 2016 newsletter article.

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