Safety alerts
Here you will find key paediatric patient safety alerts.
Teva UK Limited is reporting a minor typographical error on the carton for Lansoprazole Gastro-Resistant Hard Capsules 15mg. There are two instances where the dosage form is stated as “tablets” where it should state “gastro-resistant capsule, hard”.
Full information can be found on the MHRA website here.
The Royal College of Emergency Medicine (RCEM) has issued safety flashes regarding the dangers of ingested or inhaled magnets, water beads, and button/coin cell batteries. These items, often found in children’s toys, pose significant risks.
- Strong Magnets: Found in desk toys and fake piercings, these can cause intestinal injury within hours of ingestion, though symptoms may be delayed.
- Water Beads: Used in toys, stress balls, and vase fillers, these expand dramatically when exposed to liquid, posing a risk of obstruction if ingested or inhaled.
- Button/Coin Cell Batteries: Ingestion or inhalation can lead to serious harm or death due to chemical tissue erosion.
Key Recommendations for Clinicians:
- For young children and individuals with learning disabilities presenting with unexplained gastrointestinal or respiratory symptoms, inquire about potential access to these items, not just observed ingestion/inhalation.
- If the ingested/inhaled object is unknown and there is a possibility of battery, magnet, or sharp object ingestion, X-rays are indicated (water beads are radiolucent).
- Symptomatic patients who have ingested strong magnets require urgent surgical review.
For more details please see the RCEM Safety Flashes
A National Patient Safety Alert was issued by the NHS England National Patient Safety team, endorsed by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Royal College of Anaesthetists, in September 2024. This warns of the risk of oxytocin overdose if postpartum infusions are mistakenly given during labour which can lead to dangerous complications such as placental abruption and fetal distress.
Key actions for healthcare professionals include ensuring oxytocin infusions are not pre-prepared at ward level and that postpartum kits are readily available.
Full details and required actions (by 31 March 2025) on NHS England website
Healthcare professionals prescribing montelukast should be alert to the risk of neuropsychiatric reactions in all patients including children and adolescents. Reported neuropsychiatric reactions include sleep disorders, hallucinations, anxiety and depression, as well as changes in behaviour and mood. Healthcare professionals should advise patients and their caregivers to be alert to these risks and seek medical advice as soon as possible if neuropsychiatric reactions occur.
The FSA has issued new voluntary industry guidance on glycerol in slush-ice drinks, advising that they should not be sold to children four years of age and under.
At very high levels of exposure – typically when several of these products are drunk by a child in a short space of time – glycerol intoxication could cause shock, hypoglycaemia and loss of consciousness.
See the FSA for further details
Considerations:
- Is glycerol exposure in healthcare professionals differential diagnoses when reviewing a hypoglycaemic child?
- Do hospital shops sell slushies? Are parents aware of the risks?