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    General practice pharmacist scheme evaluation indicates ‘improved capacity’ as the main benefit

    Tuesday, 31 July 2018 15:31
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Umesh Modi is a chartered accountant, and Pamini Jatheeskumar is a chartered certified accountant at Silver Levene...
  Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead...
Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead pharmacist, Health and Wellbeing Directorate, Public Health England
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potassium-permanganateJanuary 5 2015

NHS England has issued a patient safety alert warning against accidental ingestion of topical preparations containing potassium permanganate.

There is particular concern that as potassium permanganate can be supplied as tablets. These are intended to be dissolved to make a solution for use on the skin, but a patient may be confused by this and take the tablets orally. Accidental ingestion cases have also included drinking potassium permanganate solutions intended for external use.

The warning follows an incident where a patient died after ingesting potassium permanganate. This incident is still be investigated, but “analysis of the National Reporting and Learning System (NRLS) has identified 43 incidents in the past three and a half years where potassium permanganate tablets have been ingested orally by patients.

“Although none of these incidents were reported as causing severe harm or death, any later effect on the patient was not always clearly described.”

The patient safety alert, issued just before Christmas, says that packaging clearly states that potassium permanganate should not be swallowed. However, patients, carers or staff may mistakenly regard the tablets as an oral preparation as it can come in tablet form.

Risk is increased if the term ‘potassium permanganate tablets’ is used rather than ‘potassium permanganate soak’ notes the alert. There can also be confusion if the tablets are dissolved in plastic cups or jugs.

In addition, “where accidental ingestion had occurred, staff did not always appear aware of the need to treat this as a medical emergency.”

Links:

NHS England announcement

Patient Safety Alert

Practice News

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