Iatrogenic Paracetamol Overdose

Recently I came across an article detailing the tragic events of a patient in Scotland due to iatrogenic paracetamol overdose.

As my confidence on the wards is gradually building up, reading an article like this can knock you back a great deal. Discovering that something so familiar to the healthcare profession, such as paracetamol, may still result in accidental death is a stark reminder of the importance of constant vigilance.  

The patient was 19 years old and weighed 35kg, they suffered from an undiagnosed condition resulting in chronic pain, problems with hearing, short stature and learning difficulties. The patient had previously taken oral paracetamol. Due to the progression of the patients illness, the decision was made to prescribe intravenous paracetamol by a junior doctor. The patient was prescribed 1g QDS.

Consider the above. Would you make any amendments?

In the BNF it states that Adults and Children weighing over 50kg, the intravenous dose of paracetamol is 1g every 4-6 hours (max 4g daily). Adults and Children weighing 10-50kg the intravenous dose is 15mg/kg every 4-6hours (max. 60mg/kg daily). A patient weighing 35kg should receive an intravenous dose of 525mg.

The patient received 20 doses of IV paracetamol at the 1g dose. This was double the dose she should have received. The inquiry into the patients’ death reported the cause as ‘liver failure due to paracetamol toxicity due to iatrogenic paracetamol overdose’

The patient was reviewed by 11 nurses, 12 doctors (from foundation doctors to consultants) and a pharmacist. The healthcare professionals involved assumed the intravenous paracetamol dose was the same as the paracetamol oral dose and made no amendments to the prescription kardex.

The case, whilst being a terrible tragedy for the patient’s family and friends, has highlighted a significant lack of knowledge surrounding intravenous dosing of medication in all healthcare professionals.

As pharmacists, it is essential that we are competent to recognise when doses require review and not base out knowledge on assumptions due to familiarity. For me, this case has altered my practice significantly. I hope a similar effect is seen amongst other pharmacists.

For more info: http://www.nelm.nhs.uk/en/NeLM-Area/News/2011---March/18/Fatality-due-to-inadvertent-overdoses-of-intravenous-paracetamol/?query=paracetamol&rank=91