Problems identified that resulted in overdosage of patients:
(1) Dosing errors involving vials or ampules containing a high midazolam concentration.
(2) Failing to titrate the dose to the individual needs of the patient.
(3) Failing to consider drug interactions that can result in increased sedation.
(4) Failure to label syringes or to read the label on a syringe.
Recommendations:
(1) Remove or restrict ampules and vials containing high concentrations of midazolam.
(2) Stock ampules and vials of midazolam that have a low midazolam concentration.
(3) Make sure that there is an appropriate protocol for sedation using benzodiazepines. This should specify who is responsible for the sedation.
(4) Make sure that everyone administering sedation is trained and competent.
(5) Make sure that flumazenil (a benzodiazepine antagonist) is available.
(6) Identify risk factors for sedation, including age, comorbid conditions, and medications such as opioids.
(7) Titrate the midazolam dose to the needs of the patient.
(8) Document and report all episodes of oversedation. Use of flumazenil may be a surrogate marker for such episodes.
