Through its core work to review recorded patient safety events, the National Patient Safety Team identified a choking hazard involving sucrose vial caps.
The team reviewed an incident report describing deterioration in a baby admitted to hospital for treatment of bronchiolitis, a common lung infection in young children and infants that causes inflammation and congestion in the small airways (bronchioles) of the lung. On investigation, a plastic object was visible in the baby’s airway which was subsequently found to be the cap from a sucrose vial. The team conducted a further review of recorded incidents and identified similar reports describing a potential choking hazard when using sucrose vials.
Oral sucrose is used as mild pain relief to reduce short-term pain and distress during minor procedures and is administered to neonates and infants by either dropping a dose onto the tip of the tongue or a pacifier (dummy). The products available in the UK are presented in a range of containers which include small plastic vials with transparent detachable caps.
The team engaged with the manufacturers of sucrose products supplied in plastic vials in the UK. One manufacturer has added a warning alert to the patient information leaflet highlighting the potential choking hazard and agreed to explore how the cap could be modified in the future. A second manufacturer confirmed that their sucrose vials are no longer available.
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. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this 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.
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.