Neuromuscular blocking agents: enhancing safety by reducing the risk of accidental administration

Neuromuscular blocking agents (NMBAs) are often found as ward stock in critical care units to ensure their availability in case of urgent need. The unintentional administration of an NMBA to a non-intubated and non-ventilated patient can result in severe permanent injury or death. Incidents involving mix-ups with NMBAs have occurred within and outside of critical care units. Case reports are highlighted with the intent to increase practitioner awareness of situations that could lead to similar errors and to promote changes in the critical care environment in order to enhance medication safety with NMBAs.