Source · HSSIB Patient Safety Investigation
Unintentional overdose of paracetamol in adults with low bodyweight
Published 18 March 2022
Launched 8 April 2021
Published
HSIB Legacy
Medication
This investigation explores the prescription of oral paracetamol in adult inpatients who, on admission to hospital, have low bodyweight (less than 50kg).
Summary
3 observations
Safety Observations
Observation 1
Observation
It may be beneficial for electronic prescribing and medication administration systems to include an alert for oral paracetamol that prompts documentation of a patient’s weight and consideration of the risk of liver toxicity when their weight is less than 50kg.
Observation 2
Observation
It may be beneficial for the evidence on oral paracetamol and low bodyweight to be reviewed by the relevant national bodies to reach a consensus and agree standardised prescribing guidance.
Observation 3
Observation
It may be beneficial for available technological solutions, such as beds with built-in scales, to be used to weigh patients. However, the cost of such equipment makes its widespread adoption within the NHS challenging.