NHSI Patient Safety Alert

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NHSI Patient Safety Alert: Restricted Use of open Systems for Injectable Medication during interventional procedures.

Clarification for cardiology cath lab practice on behalf of BCS/NHSI


The cardiology cath lab community have been discussing how to interpret and action the NHS Improvement Patient Safety Alert on the Restricted Use of Open Systems for Injectable Medication during interventional procedures, issued September 2016 (1).

This ‘directive’ alert asks healthcare providers to stop the use of open systems for injectable medication (with the single exception of where the practice is used for embolisation procedures (1). The primary focus of this alert relates to the risk of harm from accidentally injecting cleaning agents from open gallipots, or other types of open container, after mistaking them for the intended medication. Whilst removing cleaning agents reduces this risk, a far more effective barrier to error is to eliminate the use of any open containers for medication intended for injection.

The BCS supports the requirement of the NHS Improvement alert that it is never acceptable to draw up medication/fluids intended for injection from an open container, and confirms that the only procedure that is an exception to this is related to the use of embolization particles (3).

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