Avoiding midazolam overdose: summary of a safety report from the National Patient Safety AgencyBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4459 (Published 19 November 2009) Cite this as: BMJ 2009;339:b4459
All rapid responses
I would like to congratulate Tara Lamont et all for writing this
timely article on such an important subject.
Any drug how safe it is can still kill if we do not understand the
pharmacodynamics,pharmacokinetics and physiology. The most important thing
is commonsense. We all make mistakes but making the same twice is
criminal. We must learn from others mistake.
Making midazolam available in 1mg/ml concentration is a good idea but
we should not repeat the same mistake (like borrowing Potassium chloride)
of borrowing different concentration midazolam from other places which
store the drug like ICU and operating rooms.
Teamwork will play important role in this regard. People who use the
drug on regular basis should know how to manage the side effects like the
anesthetists do. ABC approach to manage the complications should in most
of cases see us through when you are stumped. Every patient should have
minimum monitoring, ECG, SpO2, NIBP attached and monitored as per
AAGBI/RCoA guidelines. Every patient should receive oxygen either by nasal
cannula or facemask. If the patient has airway obstruction, learn to
relieve the obstruction by head tilt, chin lift and jaw thrust and
maintain the patent airway until patient wakes up. Learn to use airway
adjuncts like oropharyngeal and nasopharyngeal airway. Always titrate the
dose. You cannot emphasize more on pre-assessing the patient. Always
assess the risk of snoring and OSA (obstructive sleep apnea) .They are
very sensitive to sedatives. We always pick up bad habits trying to
emulate others like your consultants (especially operating theatres)
injecting in big doses of cocktail of mixtures. Trying to achieve big
numbers foregoing safety does not make any sense especially in the present
climate of litigation.
The Bristol Royal Infirmary Inquiry (July 2001 Chapter 22) in its
Final Report, The Culture of the NHS , Looking to the future, A culture of
teamwork said “Teamwork as a means of serving the patients implies a multi
-professional team and a sharing of responsibility”. In its conclusion it
said “The culture of healthcare, which so critically affects all other
aspects of the service which patients receive, must develop and change.
Fundamentally, this will be achieved through education, through learning
new ways to work and through forging new links within and between
professional groups". The anesthetists as experts in the management of
airway and who use sedatives on regular basis have the responsibility to
forge an alliance with our colleagues in educating other professionals
.There is an element of selfishness in this. I always teach my trainee
ambulance crews how to manage the airway because they are the ones arrive
on scene if I meet with an accident. You or I may be the ones who need an
OGD or colonoscopy.
Finally the words of Professor Lucian Leape"Culture is not amorphous,
nor immutable; we are not powerless to change it. It is in some respects
no more than the sum of the actions and attitudes of many individuals.
Thus, if in some crucial areas of practice we can change the rules, the
regulations and incentives, behaviour and, ultimately, attitudes will
1. Teamwork and Hospital Medicine: A Vision of the future.
Jeffrey R. Dichter
Critical Care Nurse 2003:23:8-11
2. The Bristol Royal Infirmary Inquiry (July 2001 Chapter 22) Final
Report, The Culture of the NHS, Looking to the future A culture of
Competing interests: No competing interests
Both your article and the NPSA on avoiding Midazolam overdoses were
timely. Sedation by non-anaesthetists is increasing at a relatively rapid
As an SHO working in an Emergency Department (ED) I found myself
performing supervised sedations of patients for manipulations on a regular
basis. We audited our practice and that of other local EDs and found that
there were a number of areas that would have benefitted from improvement.
We found that EDs often did not have clear formal policies on
sedation. There was no formal training for SHOs in ED sedation despite
that fact that they were performing it in all the Trusts monitored.
Proformas used did not meet the recommended guidelines. Doctors were
frequently unaware of the advice that they should be giving patients after
sedation, such as avoiding driving and alcohol and did not tend to give
written advice despite the effects of Midazolam on short-term memory.
The NPSA guidelines are extremely useful and will hopefully lead to
positive changes in reducing incidents. An attitude change is required
among non-anaesthetists using Midazolam that matches the seriousness of
Competing interests: No competing interests