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Originator: NHS Improvement

From: James Nicholls

Issue date: 17-Apr-2018 12:02:10

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • NHS Regional Offices
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • Special Health Authorities

Action category: Immediate Action

Title: Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids

Broadcast content:

Perfusion fluids are mainly used during solid organ transplantation procedures to perfuse and preserve organs. If inadvertently intravenously administered to a patient, the high potassium content of some perfusion fluid can cause cardiac arrest.

Patient safety incidents have been reported where there has been confusion between solid organ perfusion fluids and other fluids intended for administration to patients.

To prevent this risk hospitals with transplant units are asked to ensure that storage of organ perfusion fluids is reviewed to reduce the chance of confusion with other fluids intended for administration to patients. Other hospitals are asked to remove all solid organ perfusion fluids from clinical areas.



Additional information: Regional teams - this alert does not need to be cascaded to primary care.

Alert reference: NHS/PSA/W/2018/002

Action underway deadline: 20-Apr-2018

Action complete deadline: 31-May-2018

Attachments:

Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency