Neuromuscular Blocking Agents Wrong-Drug Errors at PA Medical Facilities
The Pennsylvania Patient Safety Authority released a report in its December 2009 Patient Advisory regarding wrong-drug errors of neuromuscular blocking agents at Pennsylvania medical facilities.
Patients are administered neuromuscular blocking agents (NMBAs) in emergency departments, intensive care units, interventional radiology areas and medical and surgical units to paralyze skeletal muscles during surgery conducted under general anesthesia and for patients requiring intubation for airway management. The drug renders patients unable to move or breathe and can be especially dangerous if administered to a patient not properly ventilated. They do not affect the patient’s level of consciousness, anxiety or ability to feel pain.
NMBAs are considered high alert medications because their misuse has the potential to cause catastrophic injuries or death. They should only be administered in a facility with proper equipment for intubation and oxygen administration and personnel trained to perform respiratory support and airway maintenance.
The Authority received 154 reports of medication errors involving NMBAs from Pennsylvania healthcare facilities between June 2004 and June 8, 2009. 77.9% of these reported events actually reached the patient and 9.1% resulted in harm to the patient, which rate of occurrence is nearly 13 times greater when compared to the rate of 0.7% for all medication errors reported to the Authority in that time period.
One instance of a NMBA wrong drug error included in the Authorities report:
A patient was admitted for a planned surgery. While in holding area of the OR prior to surgery, anesthesia staff started an IV [intravenous] infusion and administered what they thought was midazolam [Versed®] 1.6 mg IV. The patient immediately began flailing and reaching up to her face, and she became apneic. Ambu bag ventilation was initiated, and pulse ox was placed and was 90%. The patient was taken to the OR to be ventilated and monitored until patient awoke (approximately five minutes). The patient described being awake and paralyzed with vivid recollection.
Wrong drug errors involving NMBAs or any other medication may have contributing factors such as unsafe storage, similar product labeling or packaging, look-alike drug names or unlabeled syringes. The Authority outlined several risk reduction strategies to prevent wrong drug errors involving NMBAs including separate storage, warning labels, limiting access by dispensing NMBAs only from the pharmacy and computer reminders for the pharmacy to verify ventilatory assistance before dispensing the drug.
Some of the most common forms of hospital negligence include wrong-site surgeries, medication errors, surgical errors, development of hospital-acquired infections, improper use of anesthesia, improper treatment of a diagnosed medical condition, failure to monitor or stabilize a patient, or improper use of a medical device. Hospital negligence can result in serious injuries and even deaths. If you have been injured as the result of negligence while you were a patient in a hospital, or if a loved one died due to hospital negligence, you may be able to file a claim and collect compensation for pain and suffering, lost wages, medical expenses and other losses. Call Napoli Bern Ripka, LLP at 888-529-4669 today to discuss your legal options
