Tacrolimus – risk of overdose when converting from oral to intravenous route

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 a patient safety issue around the risk of overdose when converting tacrolimus from an oral to intravenous route.

Tacrolimus is a medicine licensed for use as prophylaxis of graft rejection following organ transplantation and is administered orally or by injection.  The doses for oral and intravenous tacrolimus are not equivalent and therefore are not interchangeable.

Through its review of patient safety incidents, the team identified a report describing how a patient’s oral dose of tacrolimus was changed to the intravenous route, without the necessary dose reduction. This resulted in a harmful overdose.

The team raised the risk of overdose when converting oral tacrolimus to an intravenous preparation with NHSX, the Medicines and Healthcare products Regulatory Authority, and the British National Formulary, who updated the tacrolimus monograph with appropriate information to highlight this risk and support safer prescribing.

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.