Neuromuscular blocking agents (NMBAs) are commonly used to paralyze skeletal muscles during surgery conducted under general anesthesia and for patients requiring in tubation for airway management. These medications are used in emergency departments, intensive care units, interventional radiology areas, and even medical and surgical units. NMBAs render patients unable to move or breathe and are considered high-alert drugs because misuse can lead to catastrophic injuries or death, especially when administered to patients who are not properly ventilated. Between June 2004 and March 2009, Pennsylvania healthcare facilities submitted 154 event reports that mentioned medication errors involving the use of NMBAs. Analysis reveals that the most common medication error event types associated with this class of medications were wrong-drug errors (37%)followed by wrong-dose/over dosage errors (16.2%).Further analysis showed that 47.4% of the intended medications were not NMBAs, including cases in which the patient was harmed. Strategies to address these problems include limiting access to NMBAs, segregating NMBAs from other medications, sequestering and affixing warning labels to vials of NMBAs stocked in the pharmacy, and requiring independent double-checks before dispensing and administering NMBAs.