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 safe prescribing of haloperidol.
Safe prescribing of haloperidol in acute hospital care can be challenging. Dosing requirements and regimens differ depending on age, clinical presentation, and existing medical history.
The team became aware of two incidents where patients had died following sedation with haloperidol where subsequent monitoring opportunities were missed. One of the incidents described a repeated tenfold overdose of haloperidol in a frail, elderly patient continued for over a week.
We raised the issue with the British Geriatric Society, who as a result published Coronavirus: Managing delirium in confirmed and suspected cases in March 2020. The guidance includes advice on pharmacological interventions for delirium when other interventions have been unsuccessful and monitoring requirements once sedation is given.
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.