Time to stop being relaxed about Neuromuscular blockers?


Background and Goal of study 

Medication safety has been highlighted as a global focus by the World Health Organisations (WHO) Third Global patient Challenge; Medication without harm.  (1) Anaesthesia is a high-risk area for medication errors, with neuromuscular blockers one of the highest risk medications. (2)
Due to recent errors at our institutions and ongoing concerns with their use, (2,3) we wanted to determine the number of ‘wrong drug’ errors nationally related to neuromuscular blockers through analysis of incidents reported to the National Reporting and Learning System (NRLS) between 2012 and 2016 . 

Methods

A request to the NRLS was submitted for incidents relating to muscle relaxants and ‘wrong drug’ errors occurring in the Operating Theatre, Emergency Department and Intensive Care between 1st January 2012 and 31st December 2016. Data was reviewed by all three authors and classified by category of incident and process error.

Results and Discussion

Overall 141 incidents were identified from the search criteria, 44 of which were excluded, leaving 97 reports, resulting in 100 incidents. Of these 75 occurred in the operating theatre.

Figure 1 shows the breakdown of incidents by category, with 37 (38%) events resulting in muscle relaxant administration to an awake patient (awake paralysis), 24 of these involved the unintended administration of Suxamethonium. 

 
Figure 1; Incident breakdown by category
Drawing up errors occurred in 22/37 awake parlaysis’ (16 of these suxamethonium), and syringe swaps 7/37 (3 suxamethonium). 

Excluding NMB storage errors, (n=11)  55 of 89 incidents were judged to have resulted in no harm to the patient, 16 low harm, 16 moderate harm, and 2 severe harm. Of 37 awake paralysis reports, 15 were categorised as resulting in no harm. 

Eighteen of 97 errors resulted in substitution of another drug instead of a muscle relaxant (omission error), 7 occurring in theatres, with the commonest drug being Suggammadex (5/7, 6/18 overall). 

Conclusion

Despite numerous publications in the past highlighting strategies to reduce drug errors in Anaesthesia, (2,3) we have shown these are still occurring. These identified incidents are likely to represent the tip of the iceberg. 

Similar to a previous review (2), these errors are largely preventable, with human error in administration and preparation of drugs the commonest theme identified. (2)

As a specialty with a strong history of patient safety, we should be leading the way in promoting the WHOs third global initiative. (1) 
In addition to implementing previous recommendations, we suggest the introduction of standardised 5ml, prefilled, colour coded syringes (to the current ISO standard for syringe labelling) would help reduce the vast majority of errors identified in our study. 

References 
1. Medication Without Harm - Global Patient Safety Challenge on Medication Safety. Geneva: World Health Organization, 2017. 
2. Arnot-Smith J, Smith AF. Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008. Anaesthesia. 2010;65:1106-113
3 Wahr JA, Abernathy JH, Lazarra EH, Keebler JR, Wall MH, Lynch I, Wolfe R, Cooper RL. Medication safety in the operating room: literature and expert-based recommendations. British Journal of Anaesthesia. 2017;118(1):32-43


06 / Time to stop being relaxed about Neuromuscular blockers?