Risk of death and severe harm from error with injectable phenytoin

A patient safety alert has been issued on the safe use of injectable phenytoin.

Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS). 

About this alert

Injectable phenytoin is used to slow and stabilise erratic electrical brain activity in, for example, status epilepticus, which is a life-threatening medical emergency.

It is a particularly complicated drug to use and careful consideration must be given around prescribing, preparation, administration and monitoring.

This alert asks providers to consider if more can be done to strengthen local guidance, training and teamwork related to the use of injectable phenytoin to reduce the risk of error. 

Other resources

The Royal College of Emergency Medicine has also issued a ‘safety newsflash alert’ to support providers to raise awareness of the risks involved in the use of phenytoin and the safe use of the drug. Specialist Pharmacy Services has provided a question and answer resource to support improved safety in the use of injectable phenytoin.

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