Medication patient safety incidents linked to rapid tranquillisation: one year's data from the National Reporting and Learning System

Abstract

Background Rapid tranquillisation (RT) is a procedure that carries both medication and non-medication related risks. It has also recently been targeted by the NHS Litigation Authority, with an entire risk management standard devoted solely to this intervention. In this study, we aim to quantify the risk associated with RT, by looking at medication patient safety incidents (PSIs) reported by all NHS healthcare providers over the course of one year. Method Medication PSIs relating to RT that occurred between 1 August 2010 and 31 July 2011 were extracted from the National Reporting and Learning System (NRLS) and analysed. Results The number of PSIs extracted from the NRLS was low and no incidents related to adverse effects or harm encountered post administration of RT. These results are not generalisable as this study describes one search strategy of what is a fragmented system for reporting RT related PSIs. Conclusions and implications for clinical practice This study indicates that the task of examining RT related PSIs in their entirety would be neither easy not simple. There needs to be a more relevant, reliable and robust system for reporting incidents related to RT.