Improving compliance with oral methotrexate guidelines

This Patient Safety Alert reissues guidance to the NHS in England and Wales to reduce the risk of patient harm associated with the incorrect dosing frequency of oral methotrexate.

Oral methotrexate is a safe and effective medication if taken at the right dose and with appropriate monitoring. However, very occasionally problems with taking the medication can cause serious harm and even death.

Since July 2004 the National Reporting and Learning Service received 165 patient safety incidents reports involving oral methotrexate. Of these, 14 happened before the launch of patient safety alert (03) on 29 July 2004 and the remaining 151 happened afterwards.

Feedback from the Safety Alert Broadcast System (SABS) indicates that 18 per cent (104 out of 569) of NHS organisations in England have still not reported having fully implemented the actions set out in patient safety alert (03).

All NHS organisations should take steps to:

• agree local action required;
  
• provide patient information before and during treatment;
  
• update prescribing and dispensing software programmes; and 
  
• review purchasing.