Patient safety incidents involving neuromuscular blockade: Analysis of the UK National Reporting and Learning System data from 2006 to 2008

Anaesthesia

Volumn 65, Issue 11, 2010, Pages 1106-1113

  Arnot Smith, J ^a   Smith, A F ^b,c  

^a ROYAL BOLTON HOSPITAL   (United Kingdom)

^b Lancaster Patient Safety Research Unit   (United Kingdom)

^c ROYAL LANCASTER INFIRMARY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ATRACURIUM; FENTANYL; MIDAZOLAM; MIVACURIUM; NEOSTIGMINE; NEUROMUSCULAR BLOCKING AGENT; ONDANSETRON; PROPOFOL; SUXAMETHONIUM;

ANAPHYLAXIS; ANESTHESIA; APNEA; ARTICLE; AWARENESS; BRONCHOSPASM; DATA BASE; DRUG HYPERSENSITIVITY; DRUG MONITORING; DRUG STORAGE; DRUG TREATMENT FAILURE; DRUG USE; EXPIRATION DATE; GENERAL ANESTHESIA; HEART ARREST; HUMAN; INCIDENT REPORT; MAJOR CLINICAL STUDY; MALIGNANT HYPERTHERMIA; MEDICAL ERROR; NEUROMUSCULAR BLOCKING; PARALYSIS; PATIENT SAFETY; RASH; THERAPY DELAY; FACTUAL DATABASE; MEDICATION ERROR; METHODOLOGY; NOMENCLATURE; SAFETY; STANDARD; STATISTICS; UNITED KINGDOM;

DATABASES, FACTUAL; ENGLAND; HUMANS; MEDICATION ERRORS; NEUROMUSCULAR BLOCKADE; NEUROMUSCULAR BLOCKING AGENTS; SAFETY MANAGEMENT; TERMINOLOGY AS TOPIC; WALES;

EID: 78049490992     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/j.1365-2044.2010.06509.x     Document Type: Article

References (40)

1. Department of Health. Building a Safer NHS for Patients. London: The Stationery Office, 2001.
2. Shaw R, Drever F, Hughes H, Osborn S, Williams S,. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care 2005; 14: 279-83.
3. Catchpole K, Bell MDD, Johnson S,. Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System. Anaesthesia 2008; 63: 340-6.
4. Thomas AN, Panchagnula U,. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2008; 63: 726-33.
5. Thomas AN, Galvin I,. Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2008; 63: 1193-7.
6. Thomas AN, McGrath BA,. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2009; 64: 358-65.
7. Claudius C, Garvey LH, Viby-Mogensen J,. The undesirable effects of neuromuscular blocking drugs. Anaesthesia 2009; 64 (Suppl. 1): 10-21.
8. Abrishami A, Ho J, Wong J, Yin L, Chung F,. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Database of Systematic Reviews 2009 (Issue 4): CD007362 DOI:.
9. Caldwell JE, Miller RD,. Clinical implications of sugammadex. Anaesthesia 2009; 64 (Suppl. 1): 66-72.
10. Smith AF,. Monitoring of neuromuscular blockade in general anaesthesia. Lancet 2010; 376: 77-9.
11. Fuchs-Buder T, Schreiber J-U, Meistelman C,. Monitoring neuromuscular block: an update. Anaesthesia 2009; 64 (Suppl. 1): 82-9.
12. Spackman K,. SNOMED Clinical Terms Fundamentals. Available at: (accessed 17/04/2010).
13. Baird M, Smith AF,. Accuracy of reporters' assignment of patient harm in anaesthetic critical incidents from the UK National Reporting and Learning Scheme. European Journal of Anaesthesiology 2009; 26 (Suppl. 45): 17AP1-5.
14. Merry AF,. Safety in anaesthesia: reporting incidents and learning from them. Anaesthesia 2008; 63: 337-9.
15. James RH,. 1000 anaesthetic incidents: experience to date. Anaesthesia 2003; 58: 856-63.
16. Smith AF, Goodwin D, Mort M, Pope C,. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. British Journal of Anaesthesia 2006; 96: 715-21.
17. Leape LL,. Error in medicine. Journal of the American Medical Association 1994; 272: 1151-7.
18. Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse incident reporting. Journal of Evaluation in Clinical Practice 1999; 5: 5-12.
19. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics 2004; 114: 729-35.
20. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J,. The frequency and nature of drug administration error during anaesthesia. Anaesthesia and Intensive Care 2001; 29: 494-500.
21. Yamamoto M, Ishikawa S, Makita K,. Medication error in anesthesia: an 8-year retrospective analysis at an urban university hospital. Journal of Anesthesia 2008; 22: 248-52.
22. Orser BA, Chen RJB, Yee DA,. Medication errors in anesthetic practice: a survey of 687 practitioners. Canadian Journal of Anesthesia 2001; 48: 139-46.
23. Fasting S, Gisvold SE,. Adverse drug errors in anesthesia and the impact of coloured syringe labels. Canadian Journal of Anesthesia 2000; 47: 1060-7.
24. Anonymous. Neuromuscular blocking agents: reducing associated wrong-drug errors. Pennsylvania Patient Safety Advisory 2009; 6: 109-14. Available at: (accessed 17/04/2010).
25. Santell JP,. Medication errors involving neuromuscular blocking agents. Joint Commission Journal on Quality and Patient Safety 2006; 32: 470-5.
26. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L,. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004; 59: 493-504.
27. Smetzer JL, Cohen M,. Preventing errors with neuromuscular blocking agents. Joint Commission Journal on Quality and Patient Safety 2006; 32: 56-9.
28. Phillips MS, Williams RL,. Improving the safety of neuromuscular blocking agents: a statement from the USP Safe Medication Use Expert Committee. American Journal of Health-System Pharmacy 2006; 63: 139-42.
29. Smith AF, Mahajan RP,. National critical incident reporting: improving patient safety. British Journal of Anaesthesia 2009; 103: 623-5.
30. Grayling M, Sweeney BP,. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia 2007; 62: 806-9.
31. Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring During Anaesthesia and Recovery. London: Association of Anaesthetists of Great Britain and Ireland, 2007.
32. Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment. London: Association of Anaesthetists of Great Britain and Ireland, 2004.
33. Arbous MS, Meursing AE, Van Kleef JW, et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102: 257-68.
34. Institute for Safe Medication Practices. Paralyzed by mistakes: preventing errors with neuromuscular blocking agents. Institute for Safe Medication Practices Medication Safety Alert 2005 Sep 22; 10: 1-3. Available at: (accessed 27/05/2010).
35. Sharma S, Smith AF, Rooksby J, Gerry R,. Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia. Anaesthesia 2006; 61: 350-4.
36. Vincent CN, Stanhope N, Crowley-Murphy M,. Reasons for not reporting adverse incidents: an empirical study. Journal of Evaluation in Clinical Practice 1999; 5: 13-21.
37. Smith AF, Boult M, Woods I, Johnson S,. Promoting patient safety through prospective risk identification: example from perioperative care. Quality and Safety in Health Care 2010; 19: 69-73.
38. Benn J, Koutantji M, Wallace LM, et al. Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care 2009; 18: 11-21.
39. National Reporting and Learning Service. Anaesthesia Report Form. Available at: (accessed 28/05/2010).
40. Boelle P-Y, Garnerin P, Sicard JF, Clergue F, Bonnet F,. Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events? Quality and Safety in Health Care 2000; 9: 203-9.