All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug.
A national safety alert was issued following several incidents, including two deaths of babies, 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.
Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake.
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 237 million 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” – unlicensed drugs used by doctors for specific treatments – are packaged and labelled by manufacturers as there is a wider concern the problem could affect other drugs.
Sodium nitrite is licensed only as a cyanide antidote and is categorised as highly toxic. It has been manufactured as a “special” alongside a licensed product used in A&Es since 2016.
Since May 2018, five incidents have been reported by NHS staff in which confusion of drugs happened.
Two incidents 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 as a result.
A review by the National Reporting and Learning System identified two further incidents where injection of licensed sodium nitrite was inadvertently administered instead of sodium nitroprusside, which is used to treat high blood pressure. There was not severe harm to the patients but NHS England warned “potentially severe harm or death could occur”.
It added: “This indicates that even with the more distinct labelling and packaging of the licensed version of sodium nitrite, there is risk of mis-selection.
“As only emergency departments require sodium nitrite, mis-selection errors in other areas are likely to be due to inadvertent supply of sodium nitrite rather than sodium bicarbonate. This error may not be identified by ward staff before the wrong drug is administered.”
Hospitals have been given until 6 November to physically check all wards for the wrong drug and to destroy any unlicensed sodium nitrite supplies.
Any NHS trust that fails to take action could have legal action taken against them by the Care Quality Commission.
NHS England said: “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’.”