Risk of death from unintended administration of sodium nitrite

A National Patient Safety Alert has been issued on the risk of death from unintended administration of sodium nitrite.

About this alert

Sodium nitrite has one licensed indication: as an antidote to cyanide poisoning. It can cause significant side effects and is categorised as highly toxic. It should only be available in Emergency Departments.

Incidents have been reported where sodium nitrite was inadvertently administered instead of sodium bicarbonate, and other sodium containing injections. As the packaging and labelling of sodium bicarbonate ampoules are similar to unlicensed sodium nitrite ampoules, mis-selection errors are likely to be due to the inadvertent supply of sodium nitrite outside of Emergency Departments.

NHS acute trusts are asked to remove sodium nitrite injections from all clinical areas except Emergency Departments, and replace unlicensed sodium nitrite ampoules with licensed sodium nitrite vials. Pharmacies and Emergency Departments are also asked to change procedures and storage policies for all ‘specialist antidotes’.

About National Patient Safety Alerts

This alert has been issued as a National Patient Safety Alert.

The NHS England and NHS Improvement patient safety team is the first national body to have been accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards . These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.

NaPSAC requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight.

Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

Related content