Health trusts ordered to destroy batches of sodium nitrate after packaging mix-up
NORTHERN Ireland health trusts have been told to destroy a powerful medicine after health care staff in England mistakenly used it because its packaging looks the same as another drug.
A national safety alert was issued following several incidents, including the deaths of two babies at hospitals in England, in which patients were inadvertently given a dose of sodium nitrite — which is used as an antidote to cyanide poisoning — rather than sodium bicarbonate.
The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers.
Sodium nitrite is licensed only as a cyanide antidote and is categorised as highly toxic.
It has been manufactured as a “special” — an unlicensed drug used by doctors for specific treatments — alongside a licensed product used in A&ES since 2016.
The drug should only be available in emergency departments and may have been supplied to medical wards by mistake.
Since May 2018, five incidents have been reported by NHS staff in which confusion of drugs happened. Two involved premature babies who needed sodium bicarbonate to help reduce acidosis in their blood. One baby died soon after the medication was given, while a second died later in neonatal intensive care.
In two other incidents, the drug was mistakenly used in place of medicine to treat high blood pressure. The patients did not suffer significant harm.
Now hospitals across the UK have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product.
Northern Ireland’s Chief Medical Officer Dr Michael Mcbride and Chief Pharmaceutical Officer Cathy Harrison have issued protocols to health trusts to ensure any stocks of the medicine are removed from all clinical areas, except emergency departments.
In a letter to the five trust chief executives, they ordered them to do this “as soon as possible and no later than November 6”. That is the deadline which has been given to health trusts across the UK to destroy any unlicensed sodium nitrite.
Any NHS trust that fails to take action could have legal action taken against them by the independent regulator.
The problem of similarities in drug packaging on busy, often short-staffed, medical wards is recognised as a persistent patient safety issue around the world. Every year in England, there are an estimated 237m medication errors in the NHS and up to a third are thought to be linked to confusion over labelling.
As a result of this latest alert, NHS England said it would be looking at how drug “specials” are packaged and labelled by manufacturers as there is a wider concern the problem could affect other drugs.