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Promoting safer use of injectable medicines

Promoting safer use of injectable medicines
Reference number
0434
Central Alert System (CAS) reference
NPSA/2007/20
Issue date28 March 2007
Action date (if applicable) (date field)31 March 2008
DH Gateway reference
7736
TypeAlert

This Patient Safety Alert highlights a number of risks in prescribing, preparing and administering injectable medicines and makes recommendations for safer use. It is supported by materials to aid implementation and embed safer practice.

 

The National Reporting and Learning Service received around 800 reports a month relating to injectable medicines between January 2005 and June 2006. The majority resulted in no or low harm to patients, but there were 25 fatal incidents and 28 of serious harm.

 

Research evidence also indicates that the incidence of errors in prescribing, preparing and administering injectable medicines is higher than for other forms of medicine. In one study, at least one error occurred in 49 per cent of intravenous medicine doses prepared and administered on hospital wards; one per cent of errors were potentially severe; and 29 per cent potentially moderate errors.

 

Action for healthcare organisations include:

  1. Risk assessing injectable medicine procedures and products in all clinical areas. Developing an action plan to minimise high risks.
  2. Ensuring up-to-date protocols and procedures exist for prescribing, preparing and administering injectable medicines.
  3. Ensuring that essential technical information on injectable medicines is available and  accessible at the point of use.
  4. Implementing a ‘purchasing for safety’ policy to promote procurement of injectable medicines with inherent safety features.
  5. Training and supervising staff.
  6. Auditing medication practice with injectable medicines as part of the annual medicines management audit programme.

 

 

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Promoting safer use of injectable medicines - Alert
Promoting safer use of injectable medicines - Alert - 763 KB 0434 - Promoting safer use of injectable medicines - Alert - 2007 - V1
Promoting safer use of injectable medicines - Alert
Promoting safer use of injectable medicines - Alert - 111 KB 0434 - Promoting safer use of injectable medicines - Alert - 2007 - V1 - CY
Preparation of injectable medicines - Workforce competence statement 2
Preparation of injectable medicines - Workforce competence statement 2 - 123 KB 0434C - Preparation of injectable medicines - Workforce competence statement 2 - 2007 - V1
Prescribing injectable medicines - Workforce competence statement 1
Prescribing injectable medicines - Workforce competence statement 1 - 117 KB 0434B - Prescribing injectable medicines - Workforce competence statement 1 - 2007 - V1
Monitoring the administration of injectable medicines - Workforce competence statement 4
Monitoring the administration of injectable medicines - Workforce competence statement 4 - 111 KB 0434E - Monitoring the administration of injectable medicines - Workforce competence statement 4 - 2007 - V1
Promoting safer use of injectable medicines - Standard operating procedure template
Promoting safer use of injectable medicines - Standard operating procedure template - 130 KB 0434F - Promoting safer use of injectable medicines - Standard operating procedure template - 2007 - V1
Promoting safer use of injectable medicines - Audit template
Promoting safer use of injectable medicines - Audit template - 242 KB 0434G - Promoting safer use of injectable medicines - Audit template - 2007 - V1
Promoting safer use of injectable medicines - Risk assessment tool
Promoting safer use of injectable medicines - Risk assessment tool - 145 KB 0434H - Promoting safer use of injectable medicines - Risk assessment tool - 2007 - V1