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Preventing fatalities from medication loading doses

Reference number
1288
Central Alert System (CAS) reference
NPSA/2010/RRR018
Issue date25 November 2010
Action date (if applicable) (date field)25 November 2011
DH Gateway reference
15159
TypeAlert

A loading dose is an initial large dose of a medicine used to ensure a quick therapeutic response. It is usually given for a short period before therapy continues with a lower maintenance dose. The use of loading doses of medicines can be complex and error prone. Incorrect use of loading doses or subsequent maintenance regimens may lead to severe harm or death.

 

NHS organisations should ensure:

 

1. All medicines used by the organisation that are likely to cause harm if loading doses and subsequent maintenance doses are not prescribed and administered correctly are risk assessed and used to produce a list of critical medicines (which may contain speciality subsections). This must include warfarin, amiodarone, digoxin, phenytoin and any other medicines identified locally.

2. There is effective communication regarding loading dose and subsequent maintenance dose regimens when prescribing, dispensing or administering critical medicines. This should include handover of patients between healthcare organisations. Tools such as loading dose work sheets, loading dose prescription charts, handover and clinical protocols, and patient-held information should be considered.

 

3. Clinical checks are performed by medical, nursing and pharmacy staff (when available) so that loading and maintenance doses are correct. Appropriate information should be available to support these checks.

 

4. Healthcare professionals in the community know when to challenge abnormal doses of the identified critical medicines.

Preventing fatalities from medication loading doses
Preventing fatalities from medication loading doses - 100 KB 1288 | Preventing fatalities from medication loading doses | Rapid Response Report | 2010-11-24 | v1
Preventing fatalities from medication loading doses supporting information
Preventing fatalities from medication loading doses supporting information - 241 KB 1288 A | Preventing fatalities from medication loading doses supporting information | Rapid Response Report | 2010-11-24 | v1