Medicines alerts & safety issues

Paraffin-containing skin preparations (emollients)

BBC News Health has recently highlighted the dangers of using paraffin-containing skin preparations whilst smoking or using naked flames. For further information see this document and leaflet which include advice for both healthcare professionals and patients.


Drug safety update: paraffin based skin emollients on dressings or clothing: fire risk (includes information on where to report incidents)

National Patient Safety Agency (now NHS Improvement)

Patient safety video

West Sussex Coroner’s Report: lower strength paraffin-based products

Risk assessment provided by Locala

Risk Assessment Template.pdf

BBC Health

West Yorkshire Fire & Rescue Service – Essential Information for Health Care Professionals

West Yorkshire Fire & Rescue Service – Paraffin based creams health care professional letter


Advice on diamorphine and intrasite gel

The CDAO are aware of the unlicensed use of Intrasite gel and Diamorphine Injection in certain settings.

The decision to use this would be a clinical judgement for the individual prescriber.

In all cases, if this is the chosen treatment, both the person administering the treatment, and the patient, must be  aware of its unlicensed status. There must also be a full audit trail for the use of the Diamorphine (including destruction details of any part ampoules that may have been discarded)

Regarding treatment suitability and evidence please contact the Yorkshire Cancer Network



A patient safety alert has been issued about the risk of severe harm and death resulting from withdrawing insulin from pen devices. This notes that

56 incidents have been reported which were associated with withdrawing insulin from insulin pens or refill cartridges:

• 12 described drawing up insulin directly from pens or cartridges

• 9 described a failure of safety needle

• 9 described incorrect technique with safety needles (healthcare professional)

• 6 described incorrect technique with safety needles (patients)

• 10 described other themes.

Extracting insulin from pen devices or cartridges is dangerous and should not happen.

A local newsletter about concern regarding high strength insulin and the dangers of taking insulin from pens or cartridges is available here:

UPDATED MARCH 2017 newsletter_concerns re high strengths insulins and withdrawing insulin


•The National Pharmacy Association have produced an Insulin Identification Checker to assist pharmacists and other relevant members of staff with selecting the correct insulin for dispensing against generic prescriptions.


Newsletters about CDs

• The South West of England has issued a newsletter about risks with morphine sulphate solution 10mg/5ml.

South West England CD Newsletter Aug 2016

• NHS England Yorkshire and The Humber has issued a newsletter about prescribing controlled drugs for temporary patients

NHS England – Yorkshire and The Humber CD Newsletter – December 2016


Patient Safety Alert – resources to support safe use of valproate

Patient Safety Alert – Resources to support safe use of valproate apr17

•Drug safety update – Advice for Healthcare Professionals:

Valproate and developmental disorders: patient review and further consideration of risk minimisation measurements


Interactions with HIV Medicines

Some commonly prescribed medicines interact with certain medicines used for HIV infection. These include corticosteroid inhalers, nasal sprays and intra-articular injections. If a corticosteroid is necessary, beclometasone is a safer option as it is less dependent on CYP3A metabolism.

The MHRA has issued a Drug Safety Update about cobicistat, ritonavir and corticosteroids.

Interactions can be checked using this website.


Public Health England – Advice for prescribers on the risk of the misuse of pregabalin and gabapentin

Please see the link to guidance  published by Public Health England on the risk of misuse of pregabalin and gabapentin; this guidance explains when to avoid starting and how to reduce / stop use.


Medicines Safety Sub-group – Nefopam bulletin

Please see the link to the Medicines Safety Bulletin that focuses on Nefopam; this bulletin also provides information on prescribing recommendations and an example of a Nefopam withdrawal regime.



Patient Safety Alert: Clozapine

A reminder of the potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus as a result of constipation and reduced gastric motility.


Benzodiazepines and risk of suicide

Patient Safety Alert: Benzodiazepines and risk of suicide

A bulletin has been produced to highlight the potential risks of suicide associated with benzodiazepine prescribing and withdrawal.