Injectable phenytoin incidents – risk of death and severe harm

Following two fatalities in the United Kingdom involving errors with use of injectable phenytoin, an alert has been issued by NHS Improvement.

The National Reporting and Learning System searched for similar incidents and identified other fatal, severe and moderate harm incidents that had occurred in the preceding three years.

In hospital areas where intravenous phenytoin is administered we suggest identifying whether the issues highlighted in the alert have or could occur and acting locally to improve the safe use of injectable phenytoin.

Read the alert here.