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National Patient Safety Agency

Close monitoring of patients prescribed lithium will reduce harm

7 December 2009


The National Patient Safety Agency (NPSA) has published new guidance for NHS and independent healthcare organisations to improve the safety of lithium therapy.


The Patient Safety Alert calls on frontline services to ensure that patients who are prescribed lithium are monitored in accordance with the National Institute for Clinical Excellence (NICE) guidelines. These stipulate that lithium blood levels should be assessed every three months, while thyroid and renal function tests should be undertaken every six months.


In addition, the Patient Safety Alert is calling on healthcare providers to ensure that:


  • there are reliable systems in place to make sure that the results of blood tests are communicated between laboratories and prescribers;
  • at the start of lithium therapy, and throughout their treatment, patients receive appropriate ongoing verbal and written information and a record book to track lithium blood levels and relevant clinical tests;
  • prescribers and pharmacists check that blood tests are being monitored regularly and that it is safe to issue a repeat prescription or dispense the prescribed lithium;
  • systems are in place to identify and deal with medicines that might adversely interact with lithium therapy.


Recommendations within the Alert have to be implemented by 31 December 2010.


NPSA’s Medical Director, Dr Kevin Cleary, said: “For implementation of this alert to be successful, there must be effective communication between the prescribing physician and the team who monitor the patient. We are also asking boards to ensure that they embed these principles within their organisations and lead the implementation of this guidance.”


Lithium can help to prevent mood swings in people with bipolar mood disorder, also known as manic depression or bipolar affective disorder. It is also used in addition to an antidepressant as a next step treatment in patients with depression whose illness has not responded to an antidepressant alone. According to the Health and Social Care Information Centre, over 824,000 prescriptions were dispensed during 2008 in England for lithium tablets.


Over the last five years, the NPSA has received over 560 patient safety incidents relating to lithium use. The majority of these incidents resulted in no or low harm. A key theme in these incidents was a lack of monitoring. Lithium monitoring and checking of key blood tests have been implicated in NHS litigations and patient deaths. 


NPSA’s Senior Pharmacist, Dr David Gerrett, said:  “An audit of lithium therapy has suggested that patients may not be provided sufficient information to make their therapy safe. A key aim of the Alert is to ensure that patients are fully informed about their therapy and its side-effects, and to be on guard for any indication of toxicity.”


Dr Gerrett added: "As part of the alert, we have provided supporting information to help NHS organisations and independent service providers implement the stipulated actions and confirm when they are compliant."


Three products have been developed through collaboration between the NPSA, the Prescribing Observatory for Mental Health (based at the Royal College of Psychiatrists' Centre for Quality Improvement), and the National Pharmaceutical Association.


These include: a patient-friendly information booklet describing what lithium is used for; a lithium alert card that patients should carry with them at all times; and a record book to track critical information, changes in blood lithium levels and specific blood tests.


Mrs Carol Paton and Professor Thomas Barnes, joint clinical leads at The Prescribing Observatory for Mental Health, said: "We would like to thank the NPSA for leading on this initiative.  We believe that the lithium patient information pack will help to ensure that patients receive important information about their medicine, including why and how often blood tests are required. In addition, the record book will facilitate communication between a patient's GP and psychiatrist.”


For more information, please visit www.nrls.npsa.nhs.uk




Note to editors:



Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dinah Lartey – 020 7927 9351 / dinah.lartey@npsa.nhs.uk

Out of hours – 0788 411 5956


The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk.