Risk of death from unintended administration of sodium nitrite
Sodium nitrite is an antidote to cyanide poisoning, and is categorised as a highly toxic product which should only be available in Emergency Departments. There have been reports of inadvertent administration instead of sodium bicarbonate, and other sodium containing injections.
Source:
NHS Improvement
SPS commentary:
This alert notes that as packaging and labelling of sodium bicarbonate ampoules are similar to unlicensed sodium nitrite ampoules, mis-selection errors are likely to be due to the inadvertent supply of sodium nitrite outside of Emergency Departments. It advises NHS acute trusts to remove sodium nitrite injections from all clinical areas except Emergency Departments, and replace unlicensed sodium nitrite ampoules with licensed sodium nitrite vials. Pharmacies and Emergency Departments are also asked to change procedures and storage policies for all ‘specialist antidotes’.