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National Patient Safety Agency

Reducing risk of midazolam overdose in adults

09 December 2008

Today (09 December 2008), the National Patient Safety Agency (NPSA) is alerting staff in the NHS and independent sector to the risks of overdosing patients with midazolam, a drug used to sedate patients undergoing procedures like endoscopy or minor surgery.


Between November 2004 and November 2008, The NPSA received 498 incidents of adult patients being given the wrong dose of midazolam injection when used for conscious sedation.  This includes the death of three patients.  48 incidents resulted in moderate harm to patients and the other 447 were low or no harm to the patients involved.


The reported incidents found that in some cases staff gave the wrong dose in error or experienced difficulty in determining the appropriate dose for individual patients.  On occasion staff lacked the necessary skills and training in sedation procedures.


To prevent further harm, the NPSA is calling for the removal of high strength midazolam from general clinical areas.  Low strength midazolam should be used, except in defined areas such as anaesthesia, intensive care, palliative medicine and particular uses (such as for syringe drivers).


Dr Kevin Cleary, Medical Director, NPSA said: “The NPSA has received reports of a number of incidents, including three deaths as a result of midazolam overdose.  This Rapid Response Report recommends the removal of high strength midazolam from general clinical areas and reminds staff of the risks when sedating patients, both of which aim to reduce the risk to patients.”


Dr Jonathan Green, recent Chairman of the British Society of Gastroenterology Endoscopy Committee, commented: “We welcome and fully endorse this new guidance from the NPSA which alerts all staff to the risks associated with sedation of patients for endoscopic procedures.  This alert will help to make these procedures safer for patients and will provide all healthcare staff with straightforward protocols when using midazolam.  This will considerably reduce the risks of sedation-related adverse events, particularly in frail and elderly patients who are most at risk.”





Notes for editors:



  • The National Patient Safety Agency is a Special Health Authority of the NHS. 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.