National Patient Safety Alert: Risk of death and severe harm from ingesting superabsorbent polymer gel granules

Source: NHS Improvement

Attached below is a safety-critical and complex National Patient Safety Alert. Implementation should be coordinated by an executive leader (or equivalent role in organisations without executive boards) and supported by clinical leaders in nursing, infection prevention and control, continence management, and falls prevention.

Summary

Superabsorbent polymer gel granules (including sachets, mats and loose powder) are used to reduce spillage onto bedding, clothing and floors when patients use urine bottles or vomit bowls, or when staff move fluid-filled containers (eg washbowls, bedpans).

In 2017, NHS Improvement issued a Patient Safety Alert warning of the asphyxiation risk associated with the use of these gel granules. A patient died after ingesting a sachet of gel granules that had been left in a urine bottle in their room.

Since 2017, there have been a further 12 reported incidents of ingestion by patients; two patients died, and two patients required emergency treatment. These involved polymer gel products left in their urine bottles or vomit bowls or left for nearby patients to use. These incident reports, and NHS purchasing patterns, suggest providers have been relying on local awareness-raising rather than reviewing their overall approach to the use of these products.

As a result of these incidents, and new guidance reinforcing that polymer gels are only required for exceptional infection control purposes this alert requires any organisation still using these products to protect patients by introducing strict restrictions on their use.

Actions required

• Hospitals, mental health units, hospices and care homes must make a single decision for each of their sites to either:

1. 1. exclude polymer gel granules (sachets, mats, loose powder) from all patient uses or
   2. restrict them to exceptional use only via a specialist team.

If option (b) is chosen, the site must provide risk assessment pro formas that consider the risk for all patients in the location, not just the patient with whom polymer gel use is intended.

• Ambulance trusts must make a single decision for their service to either:

1. 1. exclude polymer gel granules (sachets, mats, loose powder) from all patient uses or
   2. restrict their use to settings where patients are constantly observed (eg emergency ambulances).

• Community nursing and community therapy services must make a single decision for their service to either:

1. 1. exclude polymer gel granules (sachets, mats, loose powder) from all patient uses or
   2. provide risk assessment pro formas that consider risk for all people in the house, not just the patient for whom polymer is required.

• All types of setting must:

1. 1. put in place purchasing controls that block unauthorised ordering of polymer gel granules (sachets, mats, loose powder)
   2. if continued use required, purchase the product that patients are least likely to confuse with food.
   3. ensure any polymer gel for non-patient use (eg spill kits, controlled drug destruction, use by cleaning staff) is kept secure and away from patients.

Action deadline: 01/06/2020

Action by

All organisations using polymer gel products; including hospitals, mental health units, ambulance services, community services, hospices and care homes.

Failure to take action required may lead to CQC taking regulatory action

» Click here to view the alert & additional information