Harm from prescribing and administering Syntometrine when contraindicated to woman with significantly raised BP

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, the National Patient Safety Team identified an issue with Syntometrine® being administered when contraindicated in women with significantly raised blood pressure. Syntometrine® is a combination product containing oxytocin and ergometrine.

Syntometrine® is used in the active management of the third stage of labour (delivery of the placenta) and to treat excess blood loss following birth. It is contraindicated in people with significant raised blood pressure.

Current national guidance recommends that oxytocin alone, rather than syntometrine, is administered to help deliver the placenta, but a review of similar incidents showed that this is not being reflected in local practices.

The team liaised with BNF colleagues, who committed to consider this issue in future work related to Syntometrine®. NICE has also been asked to include this issue during their current review of the relevant clinical guidance in this area.

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.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. 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.