Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility

Verify neuromuscular blockers. Remind practitioners that reading labels is the first defense to avoid an error. Equally important given human fallibility, implement point-of-care barcode scanning to verify neuromuscular blockers and patients before administration. In the OR and procedural areas, if barcode scanning is not undertaken, consider alternative verification systems including speakers and touch screens that provide automatic auditory and visual verification of drugs and important alerts prior to administration (Graudins, Downey, Bui, & Dooley, 2015; Merry et al., 2011).

Use smart infusion pumps. Administer all neuromuscular blocker infusions via a programmable smart infusion pump utilizing dose error-reduction software. Smart infusion pumps should be programmed to allow selection of a neuromuscular blocker infusion only in patient care areas capable of caring for ventilated patients receiving such agents. When a neuromuscular blocker is selected in units where ventilation is possible, a clinical advisory warning should note that the drug paralyzes the respiratory muscles, and the nurse must confirm that the patient is on mechanical ventilation. The flow rate of infusions of neuromuscular blockers should be presented and entered into the pump using the same standard dosing units prescribers use (e.g., mcg/kg/minute vs. mcg/kg/hour).

Secondary Recommendations

Reduce the risk of IV admixture errors. Adopt IV workflow technology that utilizes barcode scanning of products during pharmacy IV admixture preparation. Systems that support barcode scanning and gravimetrics can ensure proper drug selection and correlation to individual patient orders. To be maximally effective, the system should be utilized for all compounded admixtures. Please refer to the ISMP Guidelines for Safe Preparation of Sterile Compounds (www.ismp.org/sc?id=461) for details (currently being updated).

Reduce the risk of batching errors. Compound one drug batch at a time, and verify and label the products before beginning any subsequent single or batch preparations.

Reduce unsafe mnemonics. Review order entry systems to identify problematic mnemonic auto-fill entries and label generation associated with neuromuscular blockers, and implement safer computer rules for mnemonics when indicated (Santell, 2006).

Provide warnings on pharmacy labels. Ensure that pharmacy work labels and infusion/product labels for neuromuscular blockers are clear and accurate, and contain all necessary warnings (Santell, 2006).

Require proper labeling. Promote accurate labeling of all infusions and syringes containing neuromuscular blockers both in the OR and in patient care locations outside the OR. (When possible, prepared and labeled syringes and bags should be provided.)

Provide access to reversal agents. Ensure all appropriate reversal agents for neuromuscular blockade are available to qualified staff who might need them in an emergency. In protocols, identify who is permitted to administer the reversal agent in an emergency and provide readily available instructions for administration (ISMP, 2016).

Flush the line. If a neuromuscular blocker has been administered, all of the drug should be flushed from the IV line or the line changed (and any source container removed) prior to extubation.