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 where the antibiotic ceftazidime was infused over 24 hours.
Ceftazidime is a broad-spectrum antibiotic used for the treatment of a range of serious infections including septicaemia, pneumonia, and urinary-tract infections.
A Serious Incident reported a potential concern about the degradation of ceftazidime, when given as an infusion over 24 hours, resulting in toxicity. Whilst most national guidance advises that ceftazidime infusions should be given over 15-30 minutes, we were aware that some manufacturers’ data includes information relating to the use of 24-hour infusions.
Our concerns were escalated to colleagues in the Medicines and Healthcare products Regulatory Authority, who worked with designated manufacturers to update their Summary of Product Characteristics to clarify information relating to the stability of ceftazidime if administered as a 24-hour infusion. The Summary of Product Characteristics is the legal document approved as part of the marketing authorisation of each medicine and it forms the basis of information for healthcare professionals on how to use each medicine.
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.