Originator: |
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National Patient Safety Alert - NHS England & NHS Improvement
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- Care Trusts
- Mental Health Trusts
- Specialists Trusts
- Learning Disabilities Trusts
- Mental Health & Social Care Trusts
- Ambulance Trusts
- Mental Health & Learning Disabilities Trusts
- Acute Trusts
- Community Trusts
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- Other contacts
- Independent Healthcare Providers (registered with CAS)
- Clinical Commissioning Groups
- Special Health Authorities
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Title: |
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Risk of death from unintended administration of sodium nitrite
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Broadcast content: |
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Sodium nitrite has one licensed indication:
as an antidote to cyanide poisoning. It can cause significant side effects and is
categorised as highly toxic. It should only be available in Emergency
Departments.
Incidents have been reported where sodium
nitrite was inadvertently administered instead of sodium bicarbonate, and other
sodium containing injections. As the packaging and labelling of sodium
bicarbonate ampoules are similar to unlicensed sodium nitrite ampoules,
mis-selection errors are likely to be due to the inadvertent supply of sodium
nitrite outside of Emergency Departments.
NHS acute trusts are asked to remove sodium
nitrite injections from all clinical areas except Emergency Departments, and
replace unlicensed sodium nitrite ampoules with licensed sodium nitrite vials.
Pharmacies and Emergency Departments are also asked to change procedures and
storage policies for all ‘specialist antidotes’.
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Additional information: |
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This alert does not need to be cascaded to primary care providers
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Action underway deadline: |
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11-Aug-2020
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Action complete deadline: |
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06-Nov-2020
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