​PSO Compass Points

The patient was admitted for a hip arthroplasty. In the operating room, the patient received a spinal anesthetic; anesthesia deepened the patient's sedation with a propofol drip and administered lidocaine. The patient soon became apneic and needed respiratory support. It was discovered that it was not lidocaine but rocuronium (a neuromuscular blocking agent) that was administered. 

Situation

By paralyzing skeletal muscles, neuromuscular blocking agents (NMBs) are useful as an adjunct to anesthesia and to facilitate intubation; however, when used in error, these medications can cause significant patient harm and even death.    

Background

ECRI Institute PSO analyzed 261 events related to NMBs. The data demonstrated that harmful events could originate in all nodes of the medication use process. Specifically, the data revealed the following:

• Administration or monitoring was a factor in 48 events. These included intravenous line mix-ups, infusion pump programming errors, or incomplete monitoring of a patient's response to a paralytic.
• NMPs were unsecured in patient care areas in 45 reports.
• A wrong drug or wrong dose was chosen during prescribing, dispensing, or administering in 45 events. The majority (81%) of the wrong-dose errors were overdoses.
• In 22 reports, the event originated during prescribing. They include prescribing incorrect doses and/or concentrations, entering orders for NMBs into the wrong patient's electronic medical record, and prescribing doses based on an outdated patient weight.
• Twelve reports cited failure to provide sedation during paralysis.
• In two reports, staff initiated or continued paralysis with NMBs despite the patient not being intubated.

Assessment

Preventing harmful errors with NMBs requires a multi-modal approach. Well-defined policies and procedures are essential for the safe and effective prescription, dispensation, storage, and administration of these medications as well as monitoring the patients who receive them.   

Recommendations

ECRI Institute PSO recommends the following:

• Develop order sets that facilitate proper prescribing (with recommended dosing and orders for necessary adjunct medications) as well as patient monitoring. Require that prescribers use organization-approved order sets and monitor compliance.  
• Segregate, sequester, and differentiate all NMBs from other medications, wherever they are stored in the organization. Differentiate these products by placing auxiliary labels on all storage bins and final medication containers (vials, syringes, and IV bags) of NMBs that state: "WARNING: PARALYZING AGENT - CAUSES RESPIRATORY ARREST."
• When verbal communication of orders cannot be avoided (e.g., during emergent situations and when working under sterile conditions), utilize a repeat-back of orders, spell unfamiliar or similar-sounding drug names, and use single digit verbal affirmation for doses (e.g., "one-five" to indicate "fifteen" and to distinguish from "fifty").
• Compare NMB concentrations and nomenclature in the organization's electronic medical record system to medication administration records and infusion pump drug libraries, ensuring that they match as closely as possible.