Time for change: improving neuromuscular blocking agent safety in Australia

Abstract

AbstractIncidents 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.