A patient is in need of an
emergency CT scan one night. There is no nurse available in the radiology suite
so the ER resident accompanies the patient for the CT scan. The patient is in
need of sedation for the scan and the resident inadvertently administers
vecuronium IV to the patient, resulting in respiratory arrest necessitating
rescuscitation.
A patient is undergoing a surgical
procedure in the OR and the surgeon asks the anesthesiologist to give IV
antibiotic. The anesthesiologist reaches into the anesthesia medicine drawer,
where all the medications are kept, and pulls out a vial of vecuronium thinking
it was the antibiotic and adds it to the IV bag. On arrival to the
post-operative recovery area it is noted that the patient is not breathing well
and she requires intubation.
We also previously mentioned a case
(June 19, 2007 Tip of the Week) where an unintended consequence of CPOE led to
inadvertent administration of a neuromuscular blocking agent to a patient.
Though these three cases were
near-misses that did not result in patient harm, they illustrate the potential life-threatening
dangers of medication errors with neuromuscular blocking agents. Neuromuscular
blocking agents (NMBA’s) are high-alert medications in that permanent injury or
death may occur as a result of inappropriate usage. An outstanding review of NMBA safety issues, contributing factors, and
potential solutions issued by the ISMP Canada appeared in the Spring
2007 publication of the Canadian Association of Critical Care Nurses (CACCN).
The article provides numerous case reports of individual NMBA incidents and
points out many of the key contributing factors. It draws heavily on
observations and recommendations from the September 22, 2005 ISMP (US) Medication Safety Alert. If you
facility/organization is looking for a good place to begin doing Failure Mode
and Effects Analysis (FMEA), the NMBA safety issue would be a great place to
start, using the key points elucidated in these two articles.
NMBA incidents turn up in all areas
of the hospital, not just ICU’s and OR’s where you might anticipate their
occurrence. Sometimes a major contributing factor is continued use of an NMBA
after ventilation is discontinued. Other times it might be continuation of an
order for an NMBA when a patient is transferred to another level of care (good
medication reconciliation should help avoid this). But look-alike/sound-alike
names can be a major contributing factor. Norcuron (vecuronium) has been
mistaken for Narcan, vecuronium for vancomycin, atracurium for Ativan, etc. In
other cases, look-alike packaging has been a major contributing factor. In
other cases, the NMBA has been in unlabelled syringes or unlabelled vials. And
lack of understanding of the nature of NMBA’s and their life-threatening
potential is often a contributing factor.
There are multiple measures that
may be taken to minimize the risk of an NMBA-related incident in your
organization. Restricted access to NMBA’s is
very important. Restricting their floor stock to areas where mechanical
ventilation is easily available, such as ICU’s and OR’s and ER’s, is one step.
However, in reading the CACCN/ ISMP Canada review, it is striking at how
supplies of NMBA’s turn up in the most unexpected places (eg. an
anesthesiologist from a nearby OR, for convenience, had placed a vial of an
NMBA in a refrigerator of a neonatal nursery where it was confused with vials
of vaccine). So while restricting access is important, there clearly must be
other safety measures taken.
In those areas where there must be
stores of NMBA’s, they should be segregated from
other medications. That would, for instance, prevent someone from
reaching into an anesthesia medication cart for an antibiotic and inadvertently
pulling out an NMBA. And you should already be avoiding unlabeled
syringes/vials/etc. as part of your Joint Commission patient safety
activities. The ISMP Canada article also stresses the importance of prompt disposal of
any unused NMBA from an patient room as soon as they are
discontinued.
Appropriate warning labels are an
extremely important safety measure for NMBA’s. The ISMP Canada article lists
several potential warning labels and color coding. A very good article on ways
to optimize the effectiveness of warnings is in the August 2006 ISMP Newsletter.
Storage of NMBA’s in automated
dispensing machines can be especially problematic. Probably most important is
only storing them in areas where they are clearly needed. Where needed, they
should be kept in single access drawers. But there needs to be a special
warning that the NMBA should not be used in patients who are not
intubated/mechanically ventilated. Such a message could be delivered in those
automated systems having the capability of messaging when an NMBA is selected
for removal from a drawer. Similarly, the type of CPOE error noted earlier
might be avoided by programming in an alert ensuring the patient is
intubated/ventilated when the physician enters an order for an NMBA.
Other measures that might be used
include standardized order sets, protocols for use, independent double checks
before administration, use of bar-coding, education/training, and availability
of point-of-service informational resources.
Of course, one needs to consider
the unintended consequences of all these solutions as well. The most important one
would be inavailability of an NMBA at a time it is needed for an emergency
intubation. One suggestion in the ISMP Canada article for outside the OR was
sealing the NMBA in intubation kits or anesthesia kits so access in only
available once the intubation kit is opened.
Lastly, one of the AHRQ M&M Conference cases
from a few years ago happened to be on an NMBA incident and it had 2 terrific
downloadable videos addressing some of the communications issues in that case.
It is well worth reading and watching the videos.
Again, consider adding NMBA Safety
to your list of things you look for in your Patient Safety Walk Rounds and
consider doing a FMEA on NMBA use in your organization.
Update from our November 2007 What’s New in the Patient
Safety World:
FMEA Related to Neuromuscular Blocking Agents
In our July 31, 2007 Tip of the Week dedicated to errors in use of neuromuscular blocking agents (MNBA’s), we recommended this is a good issue to address in FMEA (Failure Mode and Effects Analysis) in your organization. Susan Paparella, from ISMP, did exactly that in a recent issue of Journal of Emergency Nursing. The ED staff had recognized NMBA’s as high-alert drugs and were contemplating their removal from ED stores, to be replaced in kits prepared for rapid-sequence intubation. FMEA is especially useful in such situations where change is to take place, because it helps identify potential unintended consequences. The article nicely describes how you do a FMEA exercise and provides examples for scoring probability and severity and use of a hazard scoring matrix. She also lists 10 other problems commonly encountered in emergency rooms that could be candidates for FMEA.
Paparella,
Susan RN, MSN Failure
Mode and Effects Analysis: A Useful Tool for Risk Identification and Injury
Prevention. Journal of Emergency Nursing.
33(4):367-371, August 2007
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