Neuromuscular blocking agents such as Rocuronium and Suxamethonium, are labeled high-risk medications because of their history of causing injuries or death when used incorrectly. These drugs are used during tracheal intubation, during surgery, and to facilitate mechanical ventilation of critically ill patients. Due to the drugs ability to paralyze the muscles necessary for breathing, they are extremely high risk and should be handled as so.
The Institute for Safe Medicine Practices (ISMP) National Medication Errors Reporting Program (MERP) has received well over 100 reports of errors involving neuromuscular blockers. However, the number of incidents that occur is likely much higher than those reported. Errors have occurred during anesthesia in operating rooms, in emergency departments, intensive care units, and other medical and surgical units.
The most common error when it comes to neuromuscular blockers appears to be the administration of the wrong drug. A 2009 analysis of 154 events over a 5 year period showed that a neuromuscular blocker was not the intended drug in approximately half of all wrong drug errors. Practitioners thought they were administering a different drug, so patients may not have been supported with mechanical ventilation. More than 80% of these wrong-drug errors reached the patient, and approximately a quarter resulted in patient harm—a rate significantly higher when compared to less than 1% of events causing harm with all other wrong-drug errors during the same study period (1).
The most common types of errors related to neuromuscular blockers are as follows:
- Unsafe storage or neuromuscular blockers
- Look-alike packaging and labeling
- Look-alike drug names
- Unsafe mnemonics
- Drug administration after extubation
- Unlabeled and mislabeled syringes
- Orders entered into wrong electronic health record
- Knowledge deficit about drug action and required ventilation
- Syringe swaps
- Reversal agent not available
- Residual drug in tubing
- Dose or rate confusion
Improper storage of neuro blockers can be exceptionally dangerous. In one instance, the neuromuscular blocker atracurium was administered instead of hepatitis B vaccine to several infants, who developed respiratory distress. One infant sustained permanent injury and another died. An anesthesiologist from a nearby operating room had placed the atracurium vial in the nursery refrigerator near look-alike vaccine vials. Similar mix-ups with vaccines continue to occur (2).
In another instance, a respiratory therapist retrieved what he thought was a sterile water vial to prepare a nebulizer treatment, and as he was piercing the stopper, he noticed he had grabbed a vial of atracurium that someone had inadvertently returned to a respiratory box in the refrigerator. These mix ups can be avoided with segregated storage and warning labels.
Neuromuscular blockers should be stored separately from all other medications. In areas where they are needed, place the neuromuscular blockers in a lidded box or a rapid sequence intubation (RSI) kit. The most common option is to use a highly visible reddish orange, high-alert storage container. If neuromuscular blockers must be stored in automated dispensing cabinets, keep them in designated lidded pockets away from other drugs. They should also be separated in the pharmacy by being placed in lidded containers in the refrigerator. Ensure to take into account look-alike vials, syringes, and bags wherever the neuromuscular blockers are stored.
It is essential to affix warning labels on all storage bins and containers. Use a label that states, “WARNING: PARALYZING AGENT – CAUSES RESPIRATORY ARREST.” This is essential to reinforce that paralysis will occur and ventilation is required. Warning labels should not cover important label information.
Storing neuromuscular blocker safely is one of the easiest ways to reduce risk. Ensure that your medications are safely and reliably stored with proper labeling and organization. Medical-grade refrigeration also ensures that the efficacy of the products being stored is maintained. Learn more about our countertop refrigerators for storing neuromuscular blockers by following the link below.
- Pennsylvania Patient Safety Authority. Neuromuscular blocking agents: reducing associated wrong-drug errors. PA Patient Saf Advis. 2009;6(4):109-14.
- Roberts L. At least 15 children in Syria die in measles immunization campaign. Science. September 18, 2014