Pennsylvania Patient Safety Advisory Neuromuscular Blocking Agents: Reducing Associated Wrong-Drug Errors ABSTRACT given to patients who are not properly ventilated. Neuromuscular blocking agents (NMBAs) are com- Therefore, this class of medications should only be monly used to paralyze skeletal muscles during administered by staff with experience in maintain- surgery conducted under general anesthesia and for ing an adequate airway and respiratory support in patients requiring intubation for airway management. facilities where intubation can readily be performed, These medications are used in emergency depart- oxygen can be administered, and respiratory support ments, intensive care units, interventional radiology can be provided. areas, and even medical and surgical units. NMBAs render patients unable to move or breathe and are Due to the potentially devastating effects from the considered high-alert drugs because misuse can misadministration of NMBAs, clinical analysts lead to catastrophic injuries or death, especially reviewed medication error reports submitted to the when administered to patients who are not properly Pennsylvania Patient Safety Authority in which an ventilated. Between June 2004 and March 2009, NMBA was listed as the medication prescribed or Pennsylvania healthcare facilities submitted 154 event medication administered, as well as medication error reports that mentioned medication errors involving the reports in which an NMBA was mentioned in the use of NMBAs. Analysis reveals that the most com- description of the event. mon medication error event types associated with this class of medications were wrong-drug errors (37%) A Look at the Numbers followed by wrong-dose/overdosage errors (16.2%). Pennsylvania healthcare facilities submitted 154 event Further analysis showed that 47.4% of the intended reports through the Authority’s reporting system from medications were not NMBAs, including cases in June 2004 to June 8, 2009, that mentioned medica- which the patient was harmed. Strategies to address tion errors involving the use of NMBAs. Further these problems include limiting access to NMBAs, seg- breakdown by harm score, which is adapted from the regating NMBAs from other medications, sequestering National Coordinating Council for Medication Error and affixing warning labels to vials of NMBAs stocked Reporting and Prevention harm index,3 shows that in the pharmacy, and requiring independent double 77.9% (n = 120) of the events reached the patient checks before dispensing and administering NMBAs. (Pa Patient Saf Advis 2009 Dec;6[4]:109-14.) (harm index = C to I) and 9.1% (n = 14) of the events were indicated by the facility as resulting in harm to the patient (see Table 1), which is nearly 13 times greater when compared to all medication errors Neuromuscular blocking agents (NMBAs) are com- reported to the Authority (0.7%) in that time period. monly used to relax skeletal muscles during surgery A review of medication errors submitted to the U.S. conducted under general anesthesia. These agents are Pharmacopeia MedMarx® program in 2006 shows also used in emergency departments (EDs), intensive that 51% (n = 332) of errors reached the patient (cat- care units (ICUs), interventional radiology areas, and egories C to I), and 9.4% (n = 61) resulted in some even medical and surgical units for patients requiring level of patient harm (categories E to I).1 intubation for airway management.1 Analysis of the reported ages of the patient involved in NMBAs produce their effect at the neuromuscular medication errors with NMBAs reveals that more than junction by interacting with acetylcholine either by 17% (n = 27) of the reports involved pediatric patients depolarizing the motor end plate or by competing (see Table 2). The care areas most often cited in these with acetylcholine for binding sites on the motor reports include the ED (13.6%, n = 21) and the oper- end plate. This interaction prevents motor transmis- ating room (OR) (12.3%, n = 19). (See Table 3.) sion, which then prevents patient movement. After a patient is administered a dose of NMBA, progressive The predominant medication error event types paralysis develops, initially affecting the smaller mus- associated with this class of medications (see Table cle groups (e.g., face, hands). Paralysis then progresses 4) were wrong-drug errors (37%, n = 57) followed to the medium to large muscles (e.g., mouth, extremi- by wrong-dose/overdosage errors (16.2%, n = 25). A ties, torso) until all the muscle groups are paralyzed 2006 MedMarx study that looked at 599 MEDMARX and respiration ceases. It is crucial for healthcare records involving NMBAs in which at least 1 type of practitioners to remember that NMBAs do not affect error was identified, with a total of 648 types of errors a patient’s level of consciousness, pain, or anxiety. selected (more than 1 type of error was involved in These medications simply render the patient unable some cases), showed that “improper dose/quantity” to move or breathe.2 NMBAs are considered high- (28.2%) followed by “unauthorized/wrong drug” alert drugs because misuse can lead to catastrophic (27.7%) were the most common types of errors involv- injuries or death, especially when they are erroneously ing the use of NMBAs.1 Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 109 Pennsylvania Patient Safety Advisory Table 1. Reports Involving Neuromuscular Blocking Agents Grouped by Harm Score (N = 154) HARM SCORE TOTAL % OF TOTAL REPORTS (N = 154) A. Circumstances that could cause adverse events. 7 4.6% B. An event occurred, but it did not reach the individual. 27 17.5% C. An event occurred that reached the individual but did not 55 35.7% cause harm. D. An event occurred that required monitoring to confirm that it 51 33.1% resulted in no harm. E. An event occurred that contributed to or resulted in temporary 11 7.1% harm and required treatment or intervention. F. An event occurred that contributed to or resulted in temporary 2 1.3% harm and required initial or prolonged hospitalization. G. An event occurred that contributed to or resulted in 0 0% permanent harm. H. An event occurred that resulted in a near-death event. 1 0.7% I. An event occurred that contributed to or resulted in death. 0 0% Wrong-Drug Errors Involving NMBAs A trauma patient was admitted to the ED. The ED Analysis of Authority reports focused on the predomi- physician was planning to intubate the patient, and nant event type for this class of medication, as well as the nurse brought in the requested medications for potentially the most devastating: wrong-drug errors. the intubation [midazolam, fentanyl, and succinyl- If an NMBA is given in error to a patient who is not choline]. The succinylcholine had been drawn up in intubated, the respiratory muscles may be paralyzed, a syringe and labeled. The physician decided not to potentially leading to serious harm or death. Analy- intubate. An order was given to the nurse to give sis of the medications reported in the “prescribed fentanyl for pain. The nurse picked up the syringe medication” field (i.e., the intended medication the and administered 1 mL when she realized it was suc- patient was to receive) showed that 47.4% (n = 27) cinylcholine. The physician was in attendance and of the intended medications were not NMBAs and intubated the patient. The patient would have been included a variety of medications. There were six intubated prior to flight. Intubation occurred earlier cases in which the NMBA vecuronium was adminis- than planned. tered instead of the intended antibiotic cefazolin; all In the literature, other cases appear in which NMBAs of these cases resulted in harm to the patient. Table have been inadvertently administered to patients 5 lists the intended (i.e., prescribed) medications who were not receiving proper ventilatory assistance. involved in wrong-drug reports. It is important to While some of those errors have occurred in the OR, note that 80.7% of the wrong-drug errors reached most have taken place in EDs, interventional radiol- the patient (n = 46) and 22.8% (n = 13) resulted in ogy departments, ICUs, and other medical, surgical, harm to the patient. When looking at all wrong-drug and psychiatric units.4 medication errors during the reporting period under analysis, 64% (14,070 reports of 21,826 wrong-drug Contributing Factors to Wrong-Drug Errors errors) reached patients, but only 0.93% (202 reports Many wrong-drug errors can be attributed to one or of 21,826 wrong-drug errors) resulted in harm. more common contributing factors. Wrong-drug medication errors reported to the Unsafe storage. Unsafe, unnecessary, and unex- Authority include the following: pected availability of NMBAs contribute to drug A patient was admitted for a planned surgery. mix-ups. In some cases, patient care area refrigera- While in holding area of the OR prior to surgery, tors have been inadvertently stocked with NMBAs. anesthesia staff started an IV [intravenous] infusion In other reports, vials of NMBAs have been placed and administered what they thought was midazolam into adjacent or, at times, the wrong storage areas [Versed®] 1.6 mg IV. The patient immediately (i.e., anesthesia kits, automated dispensing cabinets began flailing and reaching up to her face, and she [ADCs]) where the drug was previously not stocked. became apneic. Ambu bag ventilation was initiated, An example of a storage-related event reported to the and pulse ox was placed and was 90%. The patient Authority is as follows: was taken to the OR to be ventilated and monitored A patient had a cesarean section and a healthy baby until patient awoke (approximately five minutes). was delivered. The physician ordered IV Ancef® 2 gm The patient described being awake and paralyzed prior to closing. The CRNA [certified nurse anesthe- with vivid recollection. tist] obtained [and administered] the medication Page 110 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory from the anesthesia kit that he thought was Ancef, but the patient developed respiratory insufficiency Table 2. Patient Age Groups Associated and the CRNA noted that he had administered with Reports Involving Neuromuscular vecuronium not Ancef. The CRNA attempted to Blocking Agents (N = 154) reverse the medication two times and was unsuccess- % OF TOTAL ful. The patient was then given anesthesia to enable AGE GROUP TOTAL REPORTS (N = 154) intubation. The patient was sent to the ICU for Younger than 17 27 17.5% recovery and monitoring. 17 to 64 80 52% In 2002, the Institute for Safe Medication Practices 65 or older 35 22.7% (ISMP) published a case in which atracurium was administered subcutaneously instead of hepatitis Unknown 12 7.8% B vaccine to seven infants.5 The infants developed respiratory distress within 30 minutes. Five infants recovered, one sustained permanent injury, and another died. NMBAs had never been available as Table 3. Predominant Care Areas In- part of the floor stock in the nursery. For conve- volved in Medication Errors Involving nience, an anesthesiologist from a nearby OR had Neuromuscular Blocking Agents (n = 120) placed the vial of atracurium in the unit refrigerator near vaccine vials of similar appearance. % OF TOTAL UNIT TOTAL REPORTS (N = 154) According to the 2006 MedMarx report, a physician Emergency 21 13.6% removed vials of midazolam and rocuronium from department a medication cart in the OR, labeled two empty Operating room 19 12.3% syringes with the respective drug names, and was Pediatric intensive 15 9.7% interrupted while drawing up the two different drugs care unit (ICU) into the syringes.1 When he returned, he adminis- Anesthesia 15 9.7% tered the content of one of the syringes to his patient in the preoperative holding area. Shortly after, the Pharmacy 10 6.5% physician was called away to answer a page. On his Medical/surgical ICU 9 5.8% return, he found the patient unresponsive. The Medical ICU 9 5.8% patient was resuscitated, given neostigmine to reverse the respiratory paralysis, intubated, and administered Neonatal ICU 8 5.2% oxygen. It was later determined that the physician Cardiac ICU 8 5.2% had administered the syringe containing rocuronium Surgical ICU 6 3.9% instead of the intended midazolam. Similar product labeling and packaging. Vials of NMBAs have been confused with look-alike vials of Other cases have been reported in the literature. For products (e.g., normal saline, heparin, vaccines), espe- example, a number of nurses mistakenly reconstituted cially when both are stored in the refrigerator. One measles and Bacillus Calmette-Guérin vaccines with example involving similar manufacturer labeling, as pancuronium, instead of sodium chloride, and admin- well as storage issues, submitted to the Authority is istered the vaccines to healthy infants. One infant died as follows: after experiencing seizures and respiratory arrest. The A patient was scheduled for an open reduction pancuronium vial looked very similar to a vial of the internal fixation for a fracture of the left hand. The correct diluent (i.e., sodium chloride injection).6 patient had sedation and nerve block of the extrem- In another example, an ED nurse administered ity. One gram of Ancef was ordered prior to start pancuronium instead of influenza vaccine to several of surgery. After the Ancef was administered by the patients. The vials were the same size, and the labels CRNA, the patient said he felt short of breath. The were quite similar. The look-alike vials had been stored anesthesiologist came into the room at the time that next to each other in the refrigerator. The patients the patient complained of being short of breath. The experienced dyspnea and respiratory depression but, patient was immediately ventilated, anesthetized, fortunately, sustained no permanent injuries.7 and intubated. The surgery procedure was completed, Look-alike drug names. Wrong-drug errors have and the patient was extubated and taken to the postanesthesia care unit with no sequelae. After the occurred due to similarities in the drug names. Reports surgery was completed, a review of the trash and submitted to the Authority include the following: needle box led the anesthesiologist and the CRNA Narcan® 0.5 mg was ordered, and the nurse pre- to believe that vecuronium (which was located next pared Norcuron®, which was caught and not given. to Ancef in anesthesia cart) had been administered In follow-up to the event, labels were placed on the rather than Ancef (both require reconstituting and medication drawers indicting both the generic and are similar shape vials). brand name. Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 111 Pennsylvania Patient Safety Advisory Norcuron 10 mg was ordered verbally. The first nurse Similar cases have been reported to ISMP involving asked another nurse to obtain the medication from mix-ups between the proprietary names Narcan (nal- the automated dispensing cabinet. The second nurse oxone) and Norcuron (vecuronium). In one case, a repeated back “Narcan 10 mg” and the first nurse pharmacist misheard a verbal order and dispensed the stated, “yes.” The second nurse handed 5 x 2 mg NMBA Norcuron when the opioid antagonist Narcan syringes to the first nurse. Narcan was given by the 1 mg IV was ordered. The patient experienced respira- first nurse. tory arrest and required intubation. In another case, a nurse transcribed a verbal order for Narcan as “1 amp Narcan,” but a pharmacist misread the handwritten Table 4. Predominant Medication transcription as “1 amp Norcuron.” When Norcuron Error Event Types Associated with was dispensed, another nurse thought Norcuron was Neuromuscular Blocking Agents (n = 120) the generic name for Narcan and administered it % OF TOTAL to the patient, who immediately stopped breathing. EVENT TYPE NUMBER REPORTS (N =154) The patient was successfully resuscitated. In the third Wrong drug 57 37% case, a physician wrote “Narcan 1 amp IV.” An ICU nurse tried to obtain the drug from an automated Wrong dose/ 25 16.2% overdosage dispensing module where drugs were listed by their Prescription/ 7 4.5% generic names. She confused Narcan with Norcuron. refill delayed She asked a colleague, “What is the generic name for Wrong technique 6 3.9% Norcuron?” When her coworker said vecuronium, she removed the NMBA from the cabinet and gave the Extra dose 6 3.9% patient an unknown quantity from the 10 mg vial. Other 19 12.3% The patient experienced respiratory and cardiac arrest but was resuscitated, placed on mechanical ventila- tion, and transferred to the ICU.8 Table 5. Intended (Prescribed) Medications In an example involving look-alike generic drug Involved in Wrong-Drug Medication Error names, a physician prescribed vancomycin 1.5 g Reports (n = 57) IV every 12 hours for a patient, which the nurse transcribed correctly onto the medication administra- % OF WRONG- tion record. However, the pharmacist misread the MEDICATIONS DRUG ERRORS faxed copy of the handwritten order and entered PRESCRIBED TOTAL (n = 57) vecuronium into the pharmacy computer. A techni- Vecuronium (Norcuron®)* 7 12.3% cian prepared the 1.5 g dose in 250 mL using Neostigmine (Prostigmin®)* 7 12.3% 15 vials (100 mg/10 mL) of vecuronium. The check- Succinylcholine (Anectine®; 6 10.5% ing pharmacist did not recognize the error, so the bag Quelicin®)* was dispensed to the unit. Fortunately, the technician Cefazolin (Ancef®) 6 10.5% had affixed a vivid alert sticker stating, “Neuromus- cular blocker, patient must be intubated” to the bag, Midazolam (Versed®) 5 8.8% which the nurse noticed, thereby averting a serious Phenylephrine 4 7% medication error.6 (Neo-Synephrine®) Rocuronium (Zemuron®)* 3 5.3% Unlabeled syringes. NMBAs have been accidentally administered when syringes containing the drug were Cisatracurium (Nimbex®)* 3 5.3% either unlabeled or mislabeled. Although Pennsylva- Fentanyl 3 5.3% nia facilities have not submitted reports specifically Pancuronium Bromide®* 2 3.5% mentioning unlabeled syringes with NMBAs to the Authority, one example of a mislabeled syringe is Etomidate (Amidate®) 2 3.5% as follows: Propofol (Diprivan®) 2 3.5% The anesthesiologist thought he was administering Diltiazem (Cardizem®) 1 1.8% Versed. The syringe had a label that indicated it was Glycopryollate 1 1.8% Versed. There was a second label underneath that indi- cated it was rocuronium. The patient was unable to Naloxone (Narcan®) 1 1.8% speak for three to five minutes, and the anesthesiologist Mivacurium (Mivacron®)* 1 1.8% recognized that the wrong drug was given to the Acetazolamide 1 1.8% patient. This was reversed and the patient responded without any problem Norepinephrine (Levophed®) 1 1.8% One example of an unlabeled-syringe-related error No drug listed 1 1.8% reported in the literature occurred in an ED. Com- * Medications that are neuromuscular blocking agents mercially prefilled saline flush syringes were not available, so nurses prepared a supply of syringes Page 112 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory each day from multidose vials. Vecuronium had been administering. Ensure the medication is checked prepared for a trauma patient in the ED, but it was against the original order. not used. The syringe was not labeled and was inad- vertently placed with the saline flush syringes. The Supervision during initial administration. Require syringe containing vecuronium was later used to flush bedside attendance of a licensed practitioner who has the IV line of an alert three-year-old child. The child experience with intubation and airway management became flaccid, and respiratory efforts ceased. She during initial administration of an NMBA. was quickly intubated and ventilated, so permanent harm was averted.9 Prompt removal of discontinued products. Place vials, bags, and syringes of NMBAs in a sequestered bin Risk Reduction Strategies for immediate pharmacy pickup after the patient has To reduce the risk of harm from NMBAs, consider been extubated or the drug has been discontinued. multiple strategies, including both high- (e.g., limiting Increase awareness. Educate staff about the risk of access to NMBAs) and low-leverage (e.g., increasing serious errors with these high-alert drugs. Provide staff awareness) strategies. These strategies include the fol- with a list of both generic and brand names for all lowing (listed high to low):1,4,10 NMBAs available at the facility. Limit access. Based on the results of the 2004 ISMP Medication Safety Self-Assessment, NMBAs were Communication of orders. Always refer to NMBAs available as floor stock outside the OR in 80% of as “paralyzing agents” rather than muscle relaxants. participating hospitals; 59% of respondents said that Orders should not be written “prn for agitation” but when available outside the OR, these drugs were not more specifically as part of an intubation procedure sequestered from other floor stock items or labeled or to maintain a specific level of paralysis while the with auxiliary warnings.6 When possible, dispense patient is on a ventilator only. NMBAs from the pharmacy as prescribed for patients. Allow floor stock of these agents only in the OR, ED, Notes and critical care units where patients can be properly 1. Santell JP. Medication errors involving neuromuscular ventilated and monitored. blocking agents. Jt Comm J Qual Patient Saf 2006 Aug; Segregate storage. When NMBAs must be available 32(8):470-5, 417. as floor stock, have pharmacy assemble the vials in 2. Levins TT. NMBAs: manage with caution. Nurs Manage a distinct, sealed box with warnings affixed as noted 2002 Aug;33(8):38-40. below. Sequester the boxes in both refrigerated and nonrefrigerated locations. 3. National Coordinating Council for Medication Error Warning labels. Affix fluorescent red labels that Reporting and Prevention. NCC MERP index for cat- note: “Warning: Paralyzing Agent—Causes Respiratory egorizing medication errors [online]. 2001 [cited 2009 Arrest” on each vial, syringe, bag, and storage box Jun 15]. Available from Internet: http://www.nccmerp. of NMBAs. org/medErrorCatIndex.html. Safeguard storage in the pharmacy. Sequester and 4. Institute for Safe Medication Practices. Paralyzed by affix warning labels to vials of NMBAs stocked in the mistakes: preventing errors with neuromuscular blocking pharmacy. Be sure they do not obscure the vial label agents. ISMP Med Saf Alert 2005 Sep 22;10(19):1-3. in any way. 5. Institute for Safe Medication Practices. Warning! Pre- Standardize prescribing. Include the need for venti- vent mix-ups between vaccines and NMBAs. ISMP Med lation support during and after administration as well Saf Alert 2002 Dec 18;7(25):1. as a protocol that stipulates automatic discontinu- 6. Smetzer JL, Cohen M. Preventing errors with neuromus- ation of these agents after extubation and removal cular blocking agents. Jt Comm J Qual Patient Saf 2006 from a ventilator. Never accept orders to continue Jan;32(1):56-9. medications upon patient transfer. Computer reminders. Build alerts in the pharmacy 7. Institute for Safe Medication Practices. Safety brief. computer to verify the patient’s location when ISMP Med Saf Alert 1996 Oct 23;1(21):1. NMBAs are entered. If the patient is not in a critical 8. Institute for Safe Medication Practices. A caution about care unit, ED, OR, or invasive procedure area, ques- NARCAN-NORCURON confusion. ISMP Med Saf Alert tion the order and verify ventilatory assistance before 1998 Oct 7;3(20):1. dispensing the drug. If possible, establish computer- ized crosschecking of the patient’s location when 9. Paparella S. The danger of neuromuscular blocking entering NMBAs. Cautionary messages should also agents. J Emerg Nurs 2004 Jun;30(3):250-2. appear on ADC screens when applicable. Consider a 10. Phillips MS, Williams RL. Improving the safety of neu- pop-up box that asks, “Is the patient being ventilated?” romuscular blocking agents: a statement from the USP Redundancies. Consider an independent double Safe Medication Use Expert Committee. Am J Health check of these medications before dispensing and Syst Pharm 2006 Jan 15;63(2):139-42. Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 113 ? Pennsylvania Patient Safety Advisory ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following 4. Which of the following is the most effective strategy to reduce the risk of harm from NMBAs? examples or come up with your own. a. Apply warning labels to vials, syringes, and/or bags 1. All of the following are true about neuromuscular blocking of NMBAs. agents (NMBAs) EXCEPT: b. Educate staff about the risk of serious errors a. They are commonly used to relax skeletal muscles with NMBAs. during surgery conducted under general anesthesia. c. Conduct independent double checks of NMBAs before dispensing and administering. b. They can be given to patients who are not properly ventilated. d. Limit access to NMBAs by only storing them in care areas where patients can be properly ventilated and c. They should only be administered by staff with monitored. experience in maintaining an adequate airway and respiratory support. e. Build alerts in the pharmacy computer to verify the patient’s location when NMBAs are entered. d. They are often used in emergency departments, inten- sive care units, and interventional radiology areas. 5. A patient had a cesarean section and a healthy baby was delivered. The physician ordered IV Ancef® 2 gm prior to e. They interact with acetylcholine to prevent motor closing. The certified registered nurse anesthetist (CRNA) transmission, which then prevents patient movement. obtained and administered a medication from the anesthe- 2. The most commonly reported type of medication error sia kit that he thought was Ancef. The patient developed event types associated with NMBAs are . respiratory insufficiency, and the CRNA noted that he had a. wrong-technique errors administered vecuronium, a NMBA, not Ancef. b. extra-dose errors Select the most effective strategy to prevent this event from reoccurring? c. wrong-drug errors a. Remove NMBAs from anesthesia kits in the labor and d. wrong-dose/overdosage errors delivery unit. e. prescription/refill delayed errors b. Affix fluorescent red labels that note: “Warning: 3. Wrong-drug errors associated with the use of NMBAs can Paralyzing Agent—Causes Respiratory Arrest” on each be attributed to all of the following factors EXCEPT: vial of NMBA. c. Build alerts in the pharmacy computer to verify the a. Patient care area refrigerators stocked with NMBAs patient’s location when NMBAs are entered. b. Confusion with look-alike vials d. Require an independent double check of NMBAs c. Similarities in the drug names (i.e., look-alike when retrieving and before administering the drug names) medication. d. Syringes containing the drug were either unlabeled e. Educate staff about the risk of serious errors with or mislabeled. these NMBAs. Page 114 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 4—December 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.