Case study: Risk of dose error when using intraosseous lidocaine in children

We received information regarding an incident where an overdose error occurred after a verbal request for 5mg intraosseous (IO) lidocaine was made but 10mls of 2% lidocaine (200mg) was administered instead. The child suffered a cardiac arrest and later recovered.  

Lidocaine is a local anaesthetic used to reduce the pain of fluid infusion via the intraosseous route, administration directly into the marrow of a bone.

It was determined that the staff were unfamiliar with lidocaine as a pain relief for rapid fluid infusion via the IO route and the verbal prescription prevented validation checks.  

We worked with the Royal College of Emergency Medicine (RCEM) to produce a Safety Flash entitled ‘Drug errors in high-pressure or infrequent situations’ that outlined potential actions for mitigation of the risk including; preprepared cards for time critical medication, dilution of medication, separating high concentration drugs in resuscitation areas, closed loop communication and simulation.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.