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Return to Newsletter PREVENTING ERRORS WITH NEUROMUSCULAR BLOCKING AGENTS A recent article in the Institute for Safe Medication Practice (ISMP) newsletter emphasized the importance of error prevention when administering neuromuscular blocking agents(NMBAs). The article (ISMP Medication Safety Alert, September 22, 2005) indicated that more than 50 reports of misuse had occurred in recent years in operating rooms, emergency departments, intensive care units and other patient care units. Inadvertent administration of NMBAs to patients who are not receiving ventilator assistance can result in serious permanent injury or death. Documented issues include: • Mistakes due to look-a like packaging and labeling • Similar drug names • Administration after extubation • Administration of unlabeled syringes • Unsafe drug storage • Lack of knowledge of drug action and • Failure to provide ventilator support Special consideration must be taken when using NMBAs to reduce the risk of harm and guard against catastrophic misuse. The ISMP makes several safe practice recommendations for these high-alert drugs. The summary of these recommendations is listed below: • Limit access. Limit floor stock to units where patients can be properly ventilated and dispense NMBAs from the pharmacy as prescribed for patients. • Segregate and label high-alert drugs in the pharmacy. • Use specialty warning labels that indicate, “Warning: Paralyzing Agent – Causes Respiratory Arrest” for drug vial, syringe, bag, and storage box of NMBAs. • Standardize protocols for use of NMBAs such as automatic discontinuation after extubation. • Standardize prescribing to prevent misinterpretation of orders. • Set computer reminders for NMBA orders to verify ventilator assistance before dispensing. Provide automated cautions for dispensing cabinet screens to alert users to the potential risks of NMBA use. • Build in independent double checks of drugs against original orders. • Provide supervision during the initial administration of any high-alert medications. • Use point-of-care drug validation to verify drug, dose and route of administration. • Increase staff awareness of the serious risks posed by these high-alert drugs. Baxa sells a special vial label designed to prevent med errors with NMBAs. The ShrinkSafe™ Paralytic ID Band complies with the labeling recommendation above and offers a forcing function – making vial access visually and tactilely different for these high-alert drugs. These cost-effective and easy-to-use bands eliminate the potential for errors in routine administration of paralytic agents. To find out more about promoting patient safety with ShrinkSafe, contact Baxa Customer Service at 800-567-2292. Back to Top Return to Newsletter |
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