• Nine-year-old girl was given oral anaesthetic by mistake
  • HSIB says incidents have taken place throughout the NHS
  • Investigation finds inconsistent policies for safety

The Healthcare Safety Investigation Branch will review the processes for giving medication to NHS patients after a child was given an oral anaesthetic intravenously by mistake.

HSIB is investigating the incident and an interim report, published this week, said the error occurred across the NHS more than 60 times between 1 April 2016 and 30 November 2017.

In 36 cases, oral medication was administered incorrectly, including 25 cases of medication being given intravenously.

HSIB said its investigation had identified several systemic issues and there was a risk that errors would continue if no action was taken. It is planning to review the “second checker” role when NHS staff draw up medication for patients.

Investigators found some hospital staff did not always have access to specific oral syringes, which have purple plungers to differentiate them from IV syringes. However, even where oral syringes were available some staff still used IV ones. National guidance against this was published in 2007.

In 2015, a safety alert by NHS England urged providers to develop their own standards for invasive procedures. HSIB’s investigation has found these have not been consistently implemented, “particularly where invasive procedures are carried out in a non-theatre type environment”.

The bulletin said the trigger incident involved a nine-year-old girl who was admitted to a hospital day case ward for a renal biopsy in a side ward. The procedure was to be carried out with sedation, which was prescribed by a doctor for IV administration.

A nurse prepared the treatment with the prescribing doctor in the room. The nurse assumed the drug was for oral administration and was prepared with an oral syringe.

The report said the checking process “did not alert the nurse that the doctor had prescribed the drug intravenously and did not alert the doctor that the nurse had prepared the drug with the intention of it being given orally”.

The nurse was not present when the drug was administered. When the doctor struggled to connect the syringe to the IV line the drug was “decanted” to a new syringe that did connect. When the medication leaked out the doctor realised something was wrong and stopped.

The girl’s mother was informed and the child was admitted and observed for 24 hours. She underwent the procedure using general anaesthetic the next day.

HSIB said medication errors “very rarely happen as a result of an individual act; usually it is a combination of several different steps within the process of prescribing, dispensing and administering of the medicine.

“Although rare, deaths have occurred due to oral liquid medicine being given in to a vein.”

Investigators will continue their investigation and could make safety recommendations for the NHS.

Issues they will consider include the effectiveness of processes for prescribing, preparing and administering medication, and the role of the “second checker” in drug preparation and administration. The contextual, environmental and human factors that influenced inadvertent administration of oral liquid into a vein will also be examined.