NHS Patient Safety Alerts

Quetiapine oral suspension contains double the intended active ingredient (166 units, Oct 2025-Jan 2026). Cease distribution.

Fresenius Kabi transitioning to DEHP-free IV bags with supply shortages through September 2026.

Epidural bag supply issues from Sandoz and Fresenius Kabi expected until at least March 2026.

Prevent delays in administering rasburicase for tumour lysis syndrome. Ideally given within one hour in high-risk cases.

Multiple TB medications intermittently available through at least end of 2025.

Bumetanide 1mg tablets stock depletion through mid-August 2025. Furosemide available as alternative.

UK-wide Burkholderia stabilis outbreak linked to contaminated skin cleansing wipes.

Promixin colistimethate inhalation powder phased out May 2025. Ensure continuity of care.

Supplements NatPSA/2024/007/DHSC. Continued limited Creon supplies through 2026.

Shortage of Mo-99/Tc-99m generators used in nuclear medicine diagnostic imaging.

Kay-Cee-L discontinuing late November 2024. Supersedes NatPSA/2024/008/DHSC.

Cease pre-preparing oxytocin infusions at ward level. Higher postnatal dose accidentally given before birth harms mother and infant.

Limited Human Albumin stock July-December 2024. Prioritise for critical patients.

Impending Kay-Cee-L shortage from late September 2024. Superseded by NatPSA/2024/011/DHSC.

Limited Creon 10,000 and 25,000 capsule supplies with constraints until 2026.

Supply shortage of Orencia ClickJect (abatacept) pre-filled pens for rheumatoid arthritis.

Supply shortage of Erelzi (etanercept) pre-filled pens for autoimmune conditions.

TACO caused 111 deaths (39.2% of transfusion fatalities) 2010-2022. Implement risk assessments and staff training.

Supply shortage of salbutamol nebuliser liquid unit dose vials.

Replace Luer connectors with NRFit for intrathecal/epidural procedures to prevent fatal wrong-route administration.

GLP-1 RA supply not expected to normalise until at least end of 2024. Supersedes NatPSA/2023/008/DHSC.

Patients switched between Tresiba concentrations incorrectly advised on dosing, causing errors and hospitalisation.

Burkholderia cenocepacia outbreak linked to contaminated carbomer-containing eye products.

Euroking maternity IT system has data overwrite and forward-copy bugs. Providers must review and eliminate risks.

New valproate prescribing controls from January 2024. Must not start in patients under 55 unless two specialists approve.

Supply disruptions affecting multiple ADHD medications due to manufacturing issues and increased global demand.

18 deaths and 54 serious injuries 2018-2022. Update policies, train staff, ensure risk assessments for all bed rail patients.

Very limited supplies of all GLP-1 receptor agonists. Discourages off-label use for obesity; conserve stock for diabetes.

Address medication errors in severe hyperkalaemia. 30ml of 10% calcium gluconate required for full dose.

Permanently withdraw Philips V60 ventilators from clinical use due to risk of unexpected shutdown without warning alarm.

Urgent Class 1 recall of all Emerade adrenaline auto-injectors due to device failure risk. Prescribe alternative EpiPen or Jext.

Identify patients who received these lenses since October 2022, cease use, quarantine stock, arrange IOP testing.

Healthcare organisations must review guidance on safe oxygen cylinder use and conduct risk assessments in escalation/transient care areas.