Patient safety alert

Nationally, there have been reports that some batches of Prenoxad (Injectable Naloxone in a pre-filled syringe) are liable to include some kits that contain only one or no needle (the usual is two). If no needles are present in the kit, there is a risk that patients, members of the public and/or healthcare professionals may not be able to administer life-saving doses of naloxone from these kits in an emergency. This may impede the treatment for a patient with an opioid overdose, which may result in delay to intervention and possible death.

The number of kits affected is thought to be very small, and it is easy to check whether kits contain needles. It is not necessary, and in fact undesirable, to recall all the potentially affected kits/batches as this would mean withdrawing much of the intact stock from availability – a situation that would likely be far worse than the current small risk.

Actions required for healthcare professionals and service providers, including community pharmacies, emergency services, and prisons

1. Check all Prenoxad kits in place at your organisation and follow the required actions detailed in the national patient safety alert
2. Notify and provide additional support to any patients, servicer users and members of public, including peers, friends, family and carers who are confirmed or potential holders of Prenoxad Naloxone kits and ask them to check their kits. The documents below (poster for display and information sheet) have been developed to support individuals to check the kits they may hold and take action as appropriate.

• Poster
• Information sheet