Case study: Risk of harm from spinal administration of anaesthetic agent containing preservative

Through its review of recorded patient safety events, the National Patient Safety Team identified an issue related to spinal administration of lignocaine containing preservative.

Lidocaine for spinal use should be preservative free due to the epidural route of administration and the potential risk of severe neurological harm. 

We received a report describing a patient undergoing a caesarean section having their epidural topped up with lidocaine and adrenaline, where the preparation of lidocaine supplied by the pharmacy department, and subsequently administered, contained preservative.

Issues identified included clarity of product information within the pharmacy online ordering system and forms, as well as clarity of the product labelling.     

The Medicines and Healthcare products Regulatory Agency were asked to review the clarity of labelling for preservative-containing products. The pharmacy procurement leads were asked to update the Medication Safety Officer network on the principles of pharmacist involvement when purchasing ‘non-routine’ products, to ensure clinical input to purchasing decisions, and to advise them that this issue would be captured by wider Purchasing for Safety work currently underway. 

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.