Inadvertent oral administration of potassium permanganate
A joint National Patient Safety Alert has been issued by the NHS England and NHS Improvement National Patient Safety Team and the British Association of Dermatologists on the risk of inadvertent oral administration of potassium permanganate.
About this alert
Potassium permanganate is routinely used in the NHS as a dilute solution to treat weeping and blistering skin conditions. It is supplied in concentrated forms, either as a ‘tablet’ or a solution, which requires dilution before use. These concentrated forms resemble an oral tablet or drink and if ingested are highly toxic.
There have been reports of patients ingesting potassium permanganate where: healthcare staff have inadvertently administered potassium permanganate orally; patients have mistakenly taken potassium permanganate orally at home, or when left on a bedside locker; or where potassium permanganate was incorrectly prescribed as oral medication.
The alert asks both secondary and primary care providers to take action to assess if the benefit of using potassium permanganate outweighs the risk, and, if use is to continue, to ensure safer prescribing and labelling, and to ensure it is stored safely.
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 was 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).