title: Reducing risk of overdose with midazolam injection in adults: an evaluation of change in clinical practice to improve patient safety in England.
abstract: OBJECTIVE
  This study sought to evaluate potential reductions in risk associated with midazolam injection, a sedating medication, following a UK National Patient Safety Alert. This alert, 'Reducing risk of overdose with midazolam injection in adults', was sent to all National Health Service organizations as a Rapid Response Report detailing actions services should take to minimize risks.
  
  
  METHODS
  To evaluate any potential changes arising from this alert, a number of data sources were explored including reported incidents to a national reporting system for health care error, clinician survey and audit data, pharmaceutical purchasing patterns and feedback from National Health Service managers.
  
  
  RESULTS
  Prior to the Rapid Response Report, 498 incidents were received by the National Patient Safety Agency including three deaths. Post-implementation of the Rapid Response Report (June 2009), no incidents resulting in death or severe harm had been received. All organizations reported having completed the Rapid Response Report actions. Purchase and use of risk-prone, high-strength sedating midazolam by health care organizations decreased significantly as did the increased use of safer, lower strength doses (as recommended in the Rapid Response Report).
  
  
  CONCLUSIONS
  Organizations can achieve safer medication practices, better knowledge, awareness and implementation of national safer practice recommendations. Risks from inadvertent overdose of midazolam injection were reduced post-implementation of national recommendations. Ongoing monitoring of this particular adverse event will be required with a sustained patient safety message to health services to maintain awareness of the issue and reduction in the number of midazolam-related errors.
authors.affiliation: NIHR Health Service & Delivery Research Programme, National Patient Safety Agency, London, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Flood
authors.forename: Linda
authors.initials: L
authors.lastname: Matthew
authors.forename: Rachel
authors.initials: R
authors.lastname: Marsh
authors.forename: Bhavesh
authors.initials: B
authors.lastname: Patel
authors.forename: Mariama
authors.initials: M
authors.lastname: Mansaray
authors.forename: Tara
authors.initials: T
authors.lastname: Lamont
mesh_terms: D000931:Antidotes / Q000008:administration & dosage; D004305:Dose-Response Relationship, Drug; D062787:Drug Overdose / Q000188:drug therapy / Q000517:prevention & control*; D004739:England; D005442:Flumazenil / Q000008:administration & dosage; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000633:toxicity*; D007267:Injections; D008508:Medication Errors / Q000517:prevention & control*; D008874:Midazolam / Q000008:administration & dosage / Q000633:toxicity*; D061214:Patient Safety; D040242:Risk Reduction Behavior; D017751:Safety Management / Q000458:organization & administration*; D013222:State Medicine / Q000458:organization & administration
chemical_list: D000931:Antidotes; D006993:Hypnotics and Sedatives; D005442:Flumazenil; D008874:Midazolam
keywords: clinical guidelines; clinical safety; medical error