USP Drug Safety Review: Medication errors involving NMBAs

May 22, 2006

Medication errors involving neuromuscular blocking agents (NMBAs)are potentially serious and life-threatening because these agentsparalyze respiratory muscle and, if misused, can adversely affectrespiratory function. NMBAs should be administered only by staffwith experience in maintaining an adequate airway and respiratorysupport in facilities where intubation can readily be performed,oxygen can be administered, and respiratory support can beprovided.

Medication errors involving neuromuscular blocking agents (NMBAs) are potentially serious and life-threatening because these agents paralyze respiratory muscle and, if misused, can adversely affect respiratory function. NMBAs should be administered only by staff with experience in maintaining an adequate airway and respiratory support in facilities where intubation can readily be performed, oxygen can be administered, and respiratory support can be provided.

Between January 2000 and March 2003, 246 medication error records involving NMBAs were reported to the United States Pharmacopeia's MEDMARX database. Most of the errors did not result in harm, and none of the reported errors resulted in death. Nevertheless, 17% of errors reached the patient and required monitoring to confirm that the error resulted in no harm to the patient or required intervention to preclude harm. Another 10% of the errors may have contributed to or resulted in temporary harm to the patient and required either intervention or prolonged hospitalization.

Types of error

Contributing causes, factors

At least one cause of error was identified in 211 records in the MEDMARX database, with 395 causes of error selected (more than one cause of error was identified in many cases). The single most common cause was performance (human) deficit, identified as a cause of error in 45% of records involving NMBAs. Other common causes of error were: procedure/protocol not followed (19%); calculation error (13%); knowledge deficit (12%); communication (11%); and drug distribution system (10%).

In 53 MEDMARX records, 79 contributing factors were identified. Distractions were identified in 49% of the 53 records. Emergency situation and increased workload each contributed to errors in another 21% of cases. Inexperienced staff was thought to contribute to the error in eight (15%) cases.

Recommendations

To improve the safe use of NMBAs:

USP operates two complementary reporting programs: the Medication Error Reporting Program, presented in cooperation with the Institute for Safe Medication Practices, and MEDMARX. For more information on how to report errors, visit: http://www.usp.org/patientsafety.

THE AUTHOR, John P. Santell, M.S., R.Ph., is Director, Educational Program Initiatives, USP Center for the Advancement of Patient Safety.