Problem: Neuromuscular blocking agents are high-alert medications because of their well-documented history of causing catastrophic injuries or death when used in error. These drugs are used during tracheal intubation, during surgery of intubated patients, and to facilitate mechanical ventilation of critically ill patients.

By Patricia McGaffigan, RN, MS; Caitlin Y. Lorincz, MS, MA; and Tejal K. Gandhi, MD, MPH, CPPS

The availability of, and access to effective and safe treatments for pain remain serious problems in the United States (Institute of Medicine, 2011). Opioid medications are important for addressing short-term and chronic pain management. Given the benefits that they provide, usage of opioids has become widespread over the past decade. However, opioid medications also carry substantial risk, and their increased usage has introduced a host of unintended consequences across the care continuum. Given this, opioids have significant implications for patient safety. The National Patient Safety Foundation (NPSF) conducted a convenience flash poll survey to obtain a snapshot of opioid-related patient safety concerns, learning needs, and familiarity with existing seminal publications among healthcare professionals.

By the Institute for Safe Medication Practices

Medication errors in the perioperative area received widespread media attention with the publication of an article in the journal Anesthesiology (Nanji, Patel, Shaikh, Seger, and Bates, 2016). The perioperative area is one of the most medication-intensive locations in a hospital, often with more medications, particularly high-alert medications, administered per patient than other patient care units. Yet, this area of the hospital often operates with fewer medication safety strategies in place than most other patient care units. For example, the anesthesia provider often selects, prepares, labels, and administers medications without the benefit of electronic clinical decision support, pharmacy review of medication orders prior to administration, barcode scanning of products prior to administration, and other secondary checks by other healthcare providers (Nanji et al., 2016; Brown, 2014). This lack of normal checks and balances, along with the use of multiple medications, time-sensitive tasks, complex and stressful working conditions, distractions, and fatigue all contribute to making the perioperative area particularly error-prone when medications are administered.