NHS hospitals ordered to remove drug after mistakes led to two baby deaths

All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug.

A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate.

The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake.

There are an estimated 237 million medication errors in the NHS every year – with a third linked to packaging and labelling.

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Source: The Independent, 9 August 2020