AUTHOR BIOGRAPHIES
Aubrey R Stolte, College of Pharmacy, Purdue University West Lafayette
Aubrey R. Stolte (stolteaub99@gmail.com) is a PharmD candidate at Purdue University College of Pharmacy.
*Corresponding author
Yasmin M Siwy, College of Pharmacy, Purdue University West Lafayette
Yasmin M. Siwy is a PharmD candidate at Purdue University College of Pharmacy.
Sarah B Tanios, PharmD, College of Pharmacy, Purdue University West Lafayette
AbbVie, Food and Drug Administration
Sarah B. Tanios is a current Regulatory Pharmaceutical Medication Safety Fellow with Purdue University, AbbVie, and the Food and Drug Administration.
Daniel D Degnan, PharmD, MS, College of Pharmacy, Purdue University West Lafayette
Daniel D. Degnan is a courtesy clinical assistant professor at Purdue University College of Pharmacy.
Abstract
Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling, necessitating a robust process that prevents medication error, identifies near misses, and ultimately protects patients from harm. One patient at a large academic medical center (AMC) was given vecuronium, a neuromuscular blocking agent, instead of midazolam, and died as a result. Thus, AMC was tasked by the Centers for Medicare & Medicaid Services (CMS) to make a list of actions to prevent a subsequent incident. When assessing AMC’s corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies, it was revealed that 76% of strategies were of low leverage, 16% were of medium leverage, and 8% were of high leverage. In this context, AMC’s corrective action plan should have integrated more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. Overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency. Moreover, the absence of a “just culture” also plays a role in patient harm. Therefore, recognizing that medication errors in healthcare are predominantly attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.
