Safe management of Neuromuscular Blocking Agents (NMBAs) in Victorian Hospitals – led by Amy McRae, Alfred Health

This project has led to the development of state recommendations for the safe management of Neuromuscular Blocking Agents (NMBAs )in Victorian hospitals which builds on work the project lead, Amy McRae (Alfred Health), has already completed on improving the safety of NMBAs Australia wide.

Download NMBA Advisory Tool

Medicines Roundtable Lightning Presentation



Neuromuscular Blocking Agents (NMBAs) are used to produce paralysis of skeletal muscles. They are a high-risk medication used in anaesthesia and other critical care settings. The unintentional administration of an NMBA may result in permanent injury or death. (1-3)

A collaboration between VicTAG, NSW TAG, the Australian and New Zealand College of anaesthetists (ANZCA), the ACSQHC (Australian Commission on Quality and Safety in Healthcare), the TGA (Therapeutic Goods Administration) and industry led to the mandatory NMBA labelling order, that came into effect in September 2020 (4).

This labelling improvement is critical, but only one safeguard. Numerous risk-reduction strategies must be layered together and should impact as many steps of the medication- management process as feasible. (5) In addition to the NMBA labelling improvement, VicTAG recognised the need to centralise recommended NMBA risk reduction strategies for hospitals.

Development of the advisory tool

In March 2018, VicTAG funded the development of the Victorian Neuromuscular Blocking Agents Safer Practice Advisory Tool for hospitals. The tool is developed through the Victorian NMBA advisory group that provided expert advice to support the safe handling of NMBAs with the goal of reducing the risk of inadvertent administration in hospitals. The group comprised representatives from both rural and metropolitan Victorian hospitals. 

From May to June 2019, fourteen rural and metropolitan VicTAG hospitals from Victoria and Tasmania piloted the tool. The aim of this pilot was to trial the tool in a multidisciplinary ‘real practice’ setting. The pilot provided invaluable results to support its use in hospitals and importantly provide feedback to improve the tools content and design further.

On Wednesday 9th October 2019, the tool received the final endorsement from the VicTAG QUM Group and VicTAG Management Committee.

How to use the advisory tool

Importantly, the risk reduction strategies for NMBAs within this tool align with the steps of the medication management process, as defined by the ACSQHC National Safety and Quality Health Service (NSQHS) Standards (second version). These standards support health service organisations to safely supply, store, compound, manufacture, prescribe, dispense, administer, monitor and dispose of medicines. (6) 

In addition, the tools risk reduction strategies are affiliated with a specific NSQHSS action(s) in order to contribute to an action plan and demonstrate compliance with the ACSQHC NSQHS Standards. The tool is designed to be employed every three years with input from relevant stakeholders including (but not limited to) representatives from pharmacy, anaesthesia and nursing.

Pilot Results:

In May to June 2019, fourteen rural and metropolitan VicTAG healthcare services from Victoria and Tasmania piloted the advisory tool.

Key Results:

  • All healthcare services reported:
    • the tool was useful in identifying opportunities for safe handling of NMBAs and will be used as evidence for NSQHSS Standard 4 accreditation
    • 'agreed' or 'strongly agreed' that the tools layout and design was easy to use
    • plan to repeat the tool, eight plan to repeat in 3 years' and six in 1-2 years' time
    • recommend the tool be available to all Australian hospitals
  • Completion time: nine took 45 mins - 1 hour 15 mins to complete the tool, four took 2 hours or more (including follow-up and individual stakeholder consultation)
  • Risk Reduction Strategies: on average nine (range 2-24) new NMBA risk reduction strategies were identified to introduce within the healthcare services.  Most popular was 'storage' featuring the red warning statement WARNING: Paralysing Agent in front of NMBA stock



1. A.McRae. Time for Change: Proposed improvements to the labelling and packaging of Neuromuscular Blocking Agents in Australia Melbourne2015 [cited 2018 21 May]. Available from:

2. D.Bramley. Making a serious drug error shouldn't be so easy. ANZCA Bulletin. 2015:24 - 5.

3. Graudins LV, Downey G, Bui T, Dooley MJ. Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents. Joint Commission Journal on Quality and Patient Safety. 2016;42(2):86-91.

4. Therapeutic Goods Administration (TGA), Department of Health, Australian Government. Canberra [cited 2019 5 August]. Available from: 

5. Institute for Safe Medication Practices. Your High-Alert Medication List—Relatively Useless Without Associated Risk-Reduction Strategies. ISMP Med Saf Alert 2013 April 4.  

6. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards Sydney 2017 [cited 2019 10th October]. 2nd ed:[Available from