Time for change: improving neuromuscular blocking agent safety in Australia

Abstract

Incidents involving mis-selection and administration of neuromuscular blocking agents (NMBAs) leading to patient harm resulted in the initiation of activity in Victorian hospitals to review the management of this high-risk group of medicines. Local risk mitigation strategies, such as in-house labelling and restricting access, were considered partially effective, but it was recognised that a national approach was required. In 2015, hospital pharmacists — together with anaesthetist colleagues and peak patient safety organisations — made a submission to the Therapeutic Goods Administration (TGA) describing safety risks with NMBAs, with recommendations for improved NMBA labelling. This report describes the five-year process which eventually led to the TGA mandating manufacturers to place alert labelling on NMBA products. As a result of this effort, a Victorian Therapeutics Advisory Group (VicTAG) grant enabled the development of a ‘NMBA Safer Practice Advisory Tool for Australian Hospitals’, providing a standard guide to monitor the safe use of NMBAs.