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

Anesthesia Techniques and Monitors


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


Arnot-Smith J, Smith AF (Royal Bolton Hosp Foundation Trust, Bolton, UK; Royal Lancaster Infirmary, UK) Anaesthesia 65:1106-1113, 2010§



C. Lien, MD



Evidence Ranking


• B



Expert Rating


• 1



Abstract


Neuromuscular blockade is a powerful anaesthetic tool that has the potential for significant adverse outcomes. We sought to explore the national picture by analysing incidents relating to neuromuscular blockade in anaesthesia from the National Reporting and Learning System from England and Wales between 2006 and 2008. We searched the database of incidents using SNOMED CT® search terms and reading the free text of relevant incidents. There were 231 incidents arising from the use or reversal of neuromuscular blocking agents. The main themes identified were: non-availability of drugs (45 incidents, 19%), possible unintentional awareness under general anaesthesia (42 incidents, 18%), potential allergic reaction (31 incidents, 13%), problems with reversal of blockade (13 incidents, 6%), storage (13 incidents, 6%) and prolonged apnoea (11 incidents, 5%). We make recommendations to reduce human error in the use of neuromuscular blocking agents and on future incident reporting in anaesthesia.

Related posts:

Default Thumbnailof change in daily step count over five years with insulin sensitivity and adiposity: population based cohort study Default Thumbnailof Cancer: The Next Generation Default ThumbnailBeverages and Risk of Metabolic Syndrome and Type 2 Diabetes: A meta-analysis Default Thumbnailtime and haemodynamic response after thiopental vs. propofol in the elderly: a randomized trial Default Thumbnailmonitoring of neuromuscular block over the orbicularis oris muscle in anesthetized patients receiving vecuronium Default ThumbnailIs Better Than General Anesthesia During Endovascular Acute Stroke Interventions

Stay updated, free articles. Join our Telegram channel
Tags:
Jan 28, 2017 | Posted by in ANESTHESIA | Comments Off on safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008

Full access? Get Clinical Tree
Get Clinical Tree app for offline access