Confusion between different strength preparations of alfentanil
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 risk around different strength preparations of alfentanil.
Alfentanil is a potent injectable opioid used during anaesthesia and for some patients receiving palliative care.
The team became aware of two incidents where the patient was administered the higher strength Alfentanil 5 mg/ml preparation instead of the intended 500 micrograms/ml lower strength. A review of the NRLS identified 21 incidents over a two-year period that related to confusion between the two strengths of alfentanil. The incidents occurred in both primary and secondary care.
In response to these concerns:
- The MHRA have liaised with the manufacturer and the packaging has been revised to make the strength clearer
- NHSX are exploring options to differentiate the two products in pharmacy and prescribing software systems
- The National Clinical Director for Palliative and End of Life Care has highlighted the issue via the Association for Palliative Medicine and the Association of Supportive and Palliative Care Pharmacists
- Lead controlled drug accountable officers are considering potential changes to how both preparations are supplied and stored
The Medication Safety Officer Network, whose members represent individual healthcare providers across the NHS, were advised to consider choice of supplier for these preparations, as well as segregated storage.
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.