Case Study: Risks of ingestion of alcohol-based hand sanitiser

A coroner’s Prevention of Future Deaths Report described the death of a patient who in a confused state, ingested alcohol-based hand gel located by their bed. A review of similar incidents reported to the National Reporting and Learning System (NRLS) highlighted a need to ensure limited access to alcohol-based hand gels on healthcare premises, to reduce the potential for ingestion, whilst remaining accessible for infection prevention and control purposes.

The National Patient Safety Team worked alongside the NHS England Infection Prevention and Control (IPC) team who supported safe use, placement, and storage of alcohol-based hand gel products in their educational resources and toolkits. We also engaged with NHS Estates and Facilities PLACE team who subsequently  incorporated the requirement for ‘secured’ ABHG in the new PLACE audit. This will ensure routine assessment of the availability of alcohol-based hand gels. NHS Digital updated the 2022 digital assessment forms and data collection system to support this. 

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.