A Fatal Medication Error Involving Neuromuscular Blocking Agent and Insights From Wrong Drug Events in Pennsylvania
The Patient Safety Authority recently received a report describing a fatal medication error that highlights persistent risks involving wrong drug events. In this event, a patient who was prescribed a medication typically used to treat high blood calcium levels inadvertently received a fatal dose of a neuromuscular blocker (NMB) instead.
Investigation into this event revealed a series of system vulnerabilities that contributed to it. The initial error occurred when the wrong medication, which was stocked next to the intended medication, was selected from the refrigerated dispensing area in the pharmacy. A wrong drug alert was generated during the dispensing process but was overridden. Subsequently, the pharmacist performing the final verification missed the error.
To prevent such an error, facilities are encouraged to reevaluate their current processes for handling NMBs and implement proactive actions such as a force stop “wrong medication” alert in the pharmacy and the sequestration of all paralytic agents in appropriately labeled bins.
This event aligns with findings from a recently published manuscript on wrong drug events, “Wrong Drug Events Across Pennsylvania Healthcare Facilities: A Systematic Analysis of Medication Pairs, Class Patterns, and Clinical Safety Implications,” which identified NMBs as among those implicated in wrong drug events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS).
For full details and study findings, we recommend facilities and providers review that article in PSA’s journal Patient Safety at doi.org/10.33940/001c.134046.
Lessons From Event Reports
Avoiding Medication Mix-ups
Look-alike, sound-alike medications are a contributing factor in wrong drug medication errors, because the similar names are easily mixed up—presenting a high risk of patient harm. After a clinical pharmacist reported drugs with confusing names, the facility launched a look-alike drug contest, challenging pharmacy staff to identify the two medications in stock that looked the most alike. Each of the 22 contest entries was reviewed for error prevention, and those identifying manufacturer labeling issues were referred to the Institute for Safe Medication Practices (ISMP). As a result of the first contest, the facility changed purchasing practices to stock drugs with less confusing names; changed how medication is stored, to physically separate look-alikes where feasible; and revised labels prepared by the pharmacy to use inverted text and relocate key information. The contest was expanded the next year to include all hospital staff who work with medications, again followed by error reduction strategies. One of the labeling issues they reported to ISMP, concerning the look-alike pair of ephedrine and epinephrine, was published in ISMP’s newsletter and received national attention.
