Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility
Primary Recommendations
Assess labeling and packaging. Require a medication safety officer (MSO) and an anesthesia staff member to evaluate any new neuromuscular blocker’s packaging and labeling prior to procurement, and introduce auxiliary label enhancements and education, if necessary, before distribution (Graudins, Downey, Bui, & Dooley, 2016). Use brands of neuromuscular blockers that clearly differentiate the vials from other products via warnings on the label, vial cap, and metal ferrule around the rubber stopper. (All manufacturers of these agents are required to provide cautionary labeling. The development of a universal symbol for neuromuscular blockers remains to be determined [ISMP Canada, 2014]). Avoid ampuls, which have small, hard-to-read labels.
Standardize prescribing. Outside the OR or procedural areas, orders for neuromuscular blockers should only be part of an intubation protocol, or an order set to maintain a specific level of paralysis while the patient is on a ventilator only. Do not accept neuromuscular blocker orders for “use as needed for agitation.” Include the need for ventilation support during and after administration and automatic discontinuation of these agents in electronic records after extubation and removal from a ventilator. Completely disallow orders to “resume the same medications” upon patient transfer.
Use clear terminology. Always refer to these drugs as “neuromuscular blockers” or “paralyzing agents.” Never call them “muscle relaxants.”
Build computer reminders. Build alerts in the computer system to verify the patient’s location when neuromuscular blocker orders are being prescribed or entered/verified by pharmacy. If the patient is not in a critical care unit, ED, OR, or invasive procedure area, prescribers should verify that they are entering the order into the correct patient profile, and pharmacists should question the order and verify ventilatory assistance before dispensing the drug. If possible, establish computerized cross-checking of the patient’s location when entering neuromuscular blocker orders (as with other drugs limited to administration on a specific unit). Cautionary messages may also appear on ADC screens.
Limit access. Eliminate the storage of neuromuscular blockers in areas of the hospital where they are not needed (ISMP, 2016). Allow unit stock only in the OR, ED, and critical care units where patients can be properly ventilated and monitored. Consider limiting the number of neuromuscular blockers on formulary, and eliminate storage from pharmacy stock when possible. Regularly review these storage areas, both inside and outside of the pharmacy, including agents that require refrigeration, and consider the potential for mix-ups. Limiting access to these products is a strong deterrent to inadvertent use.
Segregate storage. Segregate, sequester, and differentiate all neuromuscular blockers from other medications, wherever they are stored in the organization (ISMP, 2016). In areas where they are needed, place neuromuscular blockers in a lidded box or in a rapid sequence intubation (RSI) kit. One option is a highly visible red-orange storage container available commercially (www.ismp.org/sc?id=458). If neuromuscular blockers must be stored in ADCs, keep them in separate lidded pockets, away from other drugs. Also segregate neuromuscular blockers from all other medications in the pharmacy by placing them in separate lidded containers in the refrigerator or another secure, isolated storage area. Organize anesthesia carts and trays to avoid the proximity of look-alike vials, syringes, or bags, and display the labels so they are readily visible.
Affix warning labels. Place auxiliary labels on all storage bins and final medication containers (e.g., vials, syringes, IV bags) of neuromuscular blockers that state: “WARNING: PARALYZING AGENT—CAUSES RESPIRATORY ARREST” to clearly communicate that respiratory paralysis will occur and ventilation is required. The warning labels should not cover important label information. For infusions, one hospital system also places a warning on a port tag that will be seen by nurses when they spike the bag to attach tubing. The use of shrink-wrap sleeves is questionable because they make all vials look alike.
Dispense from pharmacy. For nonurgent doses in the OR or ED, and continuous infusions in the ICU, dispense neuromuscular blockers from the pharmacy in the most ready-to-use form. The Anesthesia Patient Safety Foundation recommends the use of labeled, prefilled syringes and prepared infusions of neuromuscular blockers (and other anesthesia drugs) dispensed by pharmacy, commercially available, or outsourced, rather than self-prepared syringes or infusions (Brown, 2014). Properly labeled, prefilled syringes have the potential to improve system safety, reduce syringe swaps, and enhance work efficiency (Yang, Rivera, Fortier, Abernathy, 2016). Never dispense a neuromuscular blocker to a unit that cannot support mechanical ventilation.