NHS Patient Safety Alerts

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.