Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

Newspaper/Magazine Article

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

July 13, 2016

ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.

Neuromuscular blockers can result in serious harm if administered incorrectly. This newsletter article reports the types of errors associated with the use of these high-alert medications, such as look-alike and sound-alike problems that lead to the wrong drug being administered. Recommended strategies to reduce risks include use of standardized prescribing and smart pump technologies.

Free full text

Related Resources From the Same Author(s)

ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.

August 10, 2016

Correct use of inhalers: help patients breathe easier.

July 27, 2016

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 29, 2011

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

ISMP survey shows provider text messaging often runs afoul of patient safety.

November 29, 2017

Start the new year off right by preventing these top 10 medication errors and hazards.

January 29, 2020

Scanner beep only means the barcode has been scanned.

July 13, 2011

The texting debate: beneficial means of communication or safety and security risk?

July 12, 2017

Another tragic parenteral nutrition compounding error.

May 11, 2011

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Is an indication-based prescribing system in our future?

November 30, 2016

Understanding human over-reliance on technology.

September 28, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.

March 9, 2016

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

Rapid response team activation by patients can mitigate errors.

June 21, 2006

Building a case for medication reconciliation.

May 3, 2006

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

Preventing medication errors during codes.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children.

November 16, 2011

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

October 5, 2011

Telling true stories is an ISMP hallmark: here's why you should tell stories, too.

September 21, 2011

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Independent double checks: worth the effort if used judiciously and properly.

June 19, 2019

Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.

July 2, 2014

Misidentification of alphanumeric symbols.

June 18, 2014

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

July 2, 2008

Benefits and risks of including patients on RCA teams.

June 18, 2008

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

July 18, 2007

Two steps forward and one step back for patient safety?

August 17, 2005

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

A hard look at hard stops and workarounds in the acute care setting.

July 12, 2023

Assessing medication safety in settings not designated solely for pediatric patients.

June 28, 2023

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

July 1, 2020

Temporarily holding medication orders safely in order to prevent patient harm.

November 1, 2023

ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2.

July 18, 2018

November 14, 2007

Results of survey on pediatric medication safety—part 1 and part 2.

June 17, 2015

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

Safety requires a state of mindfulness.

March 22, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Your attention please... designing effective warnings.

September 6, 2006

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Please don't sleep through this wake-up call.

March 27, 2005

That’s the way we do things around here!

March 9, 2011

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Drug shortages threaten patient safety.

August 11, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

How has the current economy affected patient safety?

September 23, 2009

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

South Carolina medication error bill is dangerously off target.

April 29, 2015

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.

October 14, 2015

Related Resources

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

WebM&M Cases

The Impact of Communication on Medication Errors

March 15, 2021

WebM&M Cases

Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression

May 27, 2020

WebM&M Cases

Discharged with IV antibiotics: When issues arise, who manages the complications?

February 26, 2020

WebM&M Cases

Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation

November 27, 2019

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

Infection prevention in the operating room anesthesia work area.

January 30, 2019

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.

May 23, 2018

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

Sleep and circadian misalignment for the hospitalist: a review.

August 3, 2016

Medication safety in neonatal care: a review of medication errors among neonates.

July 20, 2016

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

Alarm management: first things first: using reliable data to eliminate unnecessary alarms.

December 10, 2014

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

Managing risk during transition to new ISO tubing connector standards.

August 27, 2014

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.

August 13, 2014

Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.

July 2, 2014

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.

April 2, 2014

Improvement of medication event interventions through use of an electronic database.

December 18, 2013

Understanding and managing IV container overfill.

December 4, 2013

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

September 25, 2013

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements.

September 4, 2013

Potentially inappropriate medications in a large cohort of patients in geriatric units: association with clinical and functional characteristics.

June 19, 2013

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care.

March 27, 2013

Survey results: community liaison programs to decrease hospital readmissions.

March 20, 2013

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Patients taking their own medications while in the hospital.

June 20, 2012

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

February 22, 2012

See More About The Topic

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site