Preventing Errors w/ Neuromuscular Blocking Agents (Aug. 06)

ISMP recently issued a Safety Alert called "Paralyzed by Mistakes," which warned about inadvertently giving neuromuscular blocking agents such as pancuronium to patients who aren't receiving ventilator support. This can lead to respiratory arrest. Some patients have died or incurred permanent injuries as a result of these errors.

ISMP notes that some of the errors are due to look-alike packaging and labeling. In one case, an ED nurse administered pancuronium instead of flu vaccine because the vials and labeling looked very similar. Look-alike drug names have also caused problems. In one case vancomycin was misread on a faxed medication record as vecuronium.

Giving the neuromuscular blocking agent after the patient is extubated has resulted in serious problems, too. In one case, an infusion bag of vecuronium was left in a patient's room after ventilator support had been removed. The bag was later mistaken as potassium chloride infusion and administered to the patient.

Serious patient injuries have also been caused by the opposite problem i.e., administering the neuromuscular blocking agent too soon, before the patient is intubated.

Some errors have resulted from preparing syringes from a multiple-dose vial and neglecting to label them. In one case, an unlabeled syringe of vecuronium ended up in a supply of saline flush syringes and was given to a 3-year old child.

Unsafe storage is another cause of serious mistakes. Seven infants in a hospital nursery received atracurium instead of hepatitis vaccine after an anesthesiologist placed a vial of atracurium in the nursery refrigerator near vaccine vials of similar appearance.

Not knowing enough about the drug's action can also contribute to errors. In one case, a nurse mistakenly administered vecuronium to an oncology patient who was not being ventilated, and the patient died. Had the nurse realized that the drug would paralyze the respiratory muscles, the error might have been avoided.

ISMP reminds health care practitioners that neuromuscular blocking agents are high-alert drugs and should receive your highest attention. Their alert suggests twelve ways to prevent these kinds of errors. Here are some of them:

• Limit access to the drugs, allowing floor stock only in the OR, ED and critical care units.

• Segregate storage, keeping boxes containing these agents separate in refrigerators and on shelves.

• Place warning labels on vials, syringes, infusion bags and boxes that say "Warning: paralyzing agent, causes respiratory arrest."

• Before dispensing and administering these drugs, require an independent double check of the drug against the actual order.

• And after the patient has been extubated or the drug has been discontinued, promptly isolate vials, syringes and infusion bags containing the drug in a sequestered bin for pharmacy pickup.

Additional Information:

ISMP Medication Safety Alert - Paralyzed by mistakes - Preventing errors with neuromuscular blocking agents. September 22, 2005.
http://www.ismp.org/MSAarticles/20050922.htm

Category:

News & Politics

Tags:

• Neuromuscular
• Blocking
• Agents
• FDA
• Patient
• Safety
• Drug
• Reaction

[alisonandsarah]

Good video.

[farzanatasneem]

In India pain relievers are often combined with skeletal muscle relaxants .Muscle relaxants help relax muscles, ease pain, and reduce stiffness. They are used to treat injury or other conditions affecting muscles. SMR's are a separate group of drugs than muscle relaxants used in surgery and intubations but a case of an indian nurse came in picture when she asked for a muscle relaxant from the hospital pharmacist.He sent the injection and she injected it to herself,.The case was fatal

[gorikuri]

Thanks