Paralyzed by Medical Mistakes: Neuromuscular Blockers Injure Hundreds

A new report suggests that medical mistakes related to neuromuscular blockers have injured hundreds of patients over the past several years.  The Institute for Safe Medication Practices (ISMP) operates the National Medication Errors Reporting Program (MERP).  There have been well over 100 reports filed with MERP related to errors involving neuromuscular blockers.

The ISMP believes that the incidence rate is much higher, as many medical mistakes related to medications are not properly reported.

What are Neuromuscular Blockers?

Neuromuscular blockers are medications used during surgical intubation, or during mechanical ventilation in critically ill patients.  These drugs paralyze muscles, including those required for breathing, which allows for easier intubation or ventilator support.

Patients who are given a neuromuscular blocker will experience paralysis of the small muscle groups first (hands, face, etc.) before larger muscle groups are affected.  Then, the muscles in the torso will become paralyzed, and respiration will cease.  While the patient experiences full paralysis, they are completely conscious.  Many patients experience panic and fear when respiration ceases.  Patients who are paralyzed but remain conscious may also experience pain.

Neuromuscular blockers are categorized into nondepolarizing and depolarizing.  Examples of these medications include:

Nondepolarizing:

• Atracurium
• Cisatracurium
• Nimbex
• Norcuron
• Pavulon
• Rocuronium
• Tracrium
• Vecuronium
• Zemuron

Depolarizing:

• Succinylcholine

Healthcare providers will choose which drug to use based on factors including the patient’s overall health, medical history, and emergency status.

Medical Mistakes Related to Neuromuscular Blockers

Neuromuscular blockers are considered “high-alert medications” due to a well-documented history of catastrophic injuries or death when used improperly.  Unfortunately, it seems that hundreds of patients have suffered serious injury or death due to medical mistakes with these drugs.

In 2009, researchers analyzed 154 events related to neuromuscular blockers.  In around half of those cases, the neuromuscular blocker was not the drug intended.  Healthcare providers reportedly thought that they were using a different drug, which led to a significant number of patients being exposed to the drug unnecessarily.  Researchers found that over 80 percent of these medical mistakes reached the patient, with around one-quarter of patients suffering harm as a result.

Researchers now suggest that medical mistakes related to neuromuscular blockers can be linked to common causes, including the following:

Similar Packaging and Labeling

Many medication vials look similar, which is why reading labels is so important prior to administering anything to patients.  Several reports of medical mistakes related to neuromuscular blockers include healthcare providers confusing vials and giving the wrong medication to patients.

An emergency department (ED) nurse gave several patients pancuronium instead of the ordered influenza vaccine.  Patients suffered side effects including respiratory depression, but were not permanently injured.  Several practitioners have reported concern over the similarity of drugs like Novaplus flumazenil and vecuronium.  Once the colored caps are removed, it is easy to confuse the vials.

Unsafe Mnemonics

When pharmacies enter an order, a mnemonic computer will auto-complete the drug name.  However, this can be unsafe if the drug name is not properly verified.  For example, entering “cis” for cisplatin, auto-completes to cisatracurium (a neuromuscular blocker), which can lead to a label being prepared, and the drug being dispensed.

Administration after Extubation

One medical mistake report included an ICU patient who had received vecuronium and potassium chloride infusions.  After extubation, the patient should have been given only potassium chloride, but a vecuronium infusion bag was left in the room.  The patient was given the vecuronium, which resulted in arrest, and subsequent need for intubation and ventilation assistance for an additional six hours.

Unlabeled or Mislabeled Syringes

Unlabeled or mislabeled syringes were reported in more than one incident related to neuromuscular blockers.  One example includes a prefilled syringe of vecuronium having been inadvertently placed with prefilled saline syringes in the ED.  A healthcare provider attempting to flush the IV line of a 3-year-old patient used the syringe with vecuronium instead of saline.  The child stopped breathing and went flaccid.  She required intubation and ventilation support.  Ultimately, she suffered no permanent physical injuries.

Another incident involved an anesthesiologist who was interrupted while filling syringes of rocuronium and midazolam.  When he returned, he administered one of the syringes to a patient, believing it was the midazolam.  He was called away, and when he returned, he discovered the patient unresponsive.  The healthcare team intubated the patient and administered a reversal agent.  The anesthesiologist had given the patient rocuronium instead of the midazolam.

Unsafe Storage

Unsafe storage has been linked to multiple medical mistakes, injuries, and deaths related to neuromuscular blockers.  One of the most horrifying is an incident where an OR anesthesiologist placed vials of atracurium in the nursery refrigerator.  The vials looked similar to Hepatitis B vaccines commonly stored in the same area.

Instead of receiving the Hepatitis B vaccines, several infants received syringes of atracurium.  The infants quickly went into respiratory distress.  One infant was permanently injured as a result of the medical mistake, and another sadly died.

Incorrect Entry into Electronic Health Records

Incorrectly entering information into electronic health records (EHR) is a common cause of medical mistakes.  Doctors or nurses may confuse patients with similar names, or may prescribe or administer the wrong treatment.

Researchers noted one incident where a medical resident prescribed vecuronium for the wrong patient, entering the information into the EHR.  The technician and pharmacist did not question the prescription.  A double-check was completed by two nurses before the drug was administered, but both nurses admitted that they did not know that patients required ventilation when using that drug.

Knowledge Deficit

Similar to the incident above, another report involved an ED physician who verbally ordered vecuronium and midazolam for a patient.  The physician mistakenly entered the same order electronically, but for the wrong patient.  Medications were administered, and the nurse did not recognize that the medication would paralyze respiratory muscles.  The patient was left, and quickly arrested.  The ED team quickly responded, but sadly, the resuscitation was unsuccessful and the patient died.

Swapped Syringes

When syringes are prepared, they should be labeled and placed appropriately.  In anesthesia, black and red labels are reserved for neuromuscular blockers.  Unfortunately, there have been several reports of black and red labels being applied to syringes that contain drugs other than neuromuscular blockers.  This has resulted in patients being given the incorrect medication.

Unavailable Reversal Agents

Reversal agents like sugammadex or neostigmine have reportedly been unavailable when needed in the OR, ED, and elsewhere.  One report claimed that these agents were locked in a cabinet and were not accessible.

Residual Medication in Tubing

When IV lines are clamped and not properly flushed, residual medication can remain in the line.  This is particularly dangerous with medications like neuromuscular blockers.  One incident reported occurred when a post-anesthesia care unit (PACU) nurse flushed a clamped IV line that contained rocuronium.  The nurse did not realize the tubing contained rocuronium residue.  The patient stopped breathing and moving.  A reversal agent was administered and the patient recovered.

Safety Recommendations to Reduce Medical Mistakes

Many of the medical mistakes involving neuromuscular blockers are related to inadequate safeguards, accidental administration, and failure to adhere to guidelines for ordering, selection, preparation, administration, or storage.

Neuromuscular blockers are a prime focus on the ISMP’s 2018-2019 “Targeted Medication Safety Best Practices for Hospitals”.  This guideline includes primary recommendations, which are of the utmost importance.  It also includes secondary recommendations, which are important, but are not as targeted to neuromuscular blockers.  Secondary recommendations could apply to medical mistakes related to any medication.

Primary Recommendations

Primary recommendations include the following:

• Limit Access – Neuromuscular blockers should not be stored in units where it is not needed. These drugs should only be stored in the ED, OR, and critical care units.
• Standardized Prescribing – Outside of the OF, neuromuscular blockers should only be prescribed as part of intubation procedures. These drugs should never be used as a chemical restraint.
• Computer Alerts – Computer alerts could help prevent incorrect medication being prescribed, or medications being prescribed to the wrong patient. If the computer notices that the patient is not in the OR, ED, or critical care unit, it could alert the prescriber for verification.  Pharmacists could also receive an alert when neuromuscular blockers are ordered, and then could verify applicability and necessity before dispensing.
• Proper Storage – Storage of neuromuscular blockers should be segregated from all other medications. Facilities can differentiate these drugs using brightly-colored labels that are only used for these drugs.  In facilities where storage is limited, neuromuscular blockers should be kept in a lidded container or pocket to prevent them from being confused with other drugs.
• Warning Labels – Healthcare facilities can use auxiliary labels to identify neuromuscular drugs. Use labels that include “Paralyzing Agent”, “Causes Respiratory Arrest”, or other warnings to identify these drugs and prevent mix-ups.

 Secondary Recommendations

Secondary recommendations that apply to most all medications include:

• Implement safer computer rules to reduce unsafe mnemonics.
• Ensure that neuromuscular blockers have clear, accurate labeling and all necessary warnings.
• Ensure that reversal agents are available in all applicable areas of the facility.
• Flush IV lines properly to ensure that residual is not a concern.
• Verify competency of all healthcare practitioners who may come in contact with neuromuscular blockers.

These recommendations could help healthcare facilities prevent injuries or deaths related to neuromuscular blockers.  However, it is up to the healthcare facility and staff to ensure proper protocols, monitor compliance, and take measures where necessary to ensure patient safety.

Getting Help with Medical Mistakes

If you have been harmed by a medical mistake related to a neuromuscular blocker or other medication, contact our Houston medical malpractice attorney to learn more about your legal rights.  You may be entitled to compensation for your injuries, expenses, and other losses.  To learn more, fill out our online form, or call 877-887-4850 to request a free consultation.