New guidance, produced by the National Patient Safety Agency (NPSA) and NHS organisations across England and Wales, aims to ensure safer systems are in place to care for newborn babies needing treatment with gentamicin.
The publication of the Patient Safety Alert follows reports received by the NPSA of 507 patient safety incidents between April 2008 and March 2009 relating to the use of the intravenous antibiotic. Side effects of gentamicin can include renal damage and hearing loss. In order to reduce these risks, it is important that the concentration of gentamicin in the blood is kept within the therapeutic range by giving the drug at the correct time and measuring the blood level. This latest Patient Safety Alert requires all NHS organisations to have a neonatal gentamicin protocol in place that clarifies dosage and blood level monitoring requirements. It also requires clinicians to use a care bundle approach when prescribing and administering gentamicin. Elements of the care bundle include: • Following the 24-hour clock format when prescribing gentamicin and blocking out any unused time slots on the administration record at the time of prescribing. This should assist with preventing administration at the wrong time. • Ensuring those responsible for preparing and administering gentamicin are not interrupted. They should wear disposable coloured aprons that will act as a signal to other staff that they are involved in the preparation or administration of a medicine. • Adopting a double checking prompt during the preparation and administration of gentamicin. • Administering the prescribed dose of gentamicin within one hour of the prescribed time.
