Safety snippets
Here you will find patient safety alerts and developments in paediatric patient safety.
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
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?
As of 27 May 2024, NHS England reported that 143 sites trialling Martha’s rule – see details : See here for further details
Related to the Martha’s Rule Programme, the Prevention Identification, Escalation, Response (PIER) toolkit to be produced in summer 2024 including a range of resources to support integrated care boards (ICBs) to introduce the PIER approach across their local systems. The toolkit will support and guide ICBs with pathway/system thinking for deterioration management that is system led. This suite of resources will help ICBs to use an improvement approach to design and implement a deterioration improvement plan.
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.