NHS England has issued a patient safety alert on the risk of death or serious harm from accidental ingestion of potassium permanganate preparations.
A number of incidents have occurred recently in which the wound care treatment had been swallowed by patients, rather than used externally.
“Some staff, patients and carers may accidentally treat it as an oral preparation”
Potassium permanganate can be fatal if ingested orally due to local inflammatory reactions that block the airways or cause perforations of the gastrointestinal tract.
It can also cause death through toxicity and organ failure.
The patient safety alert, which was issued yesterday, noted that potassium permanganate was available as a solution for further dilution and as a tablet preparation to be dissolved in water.
Although packaging clearly states potassium permanganate should not be swallowed, NHS England highlighted that it was very unusual for a topical preparation to come in a tablet form.
As a result, some staff, patients and carers may accidentally treat it as an oral preparation, it said.
The risk of error appears to increase when the term “potassium permanganate tablets” is used rather than a term such as “potassium permanganate soak”, noted the alert.
The risk of accidentally swallowing the solution also increases where containers were used such as plastic cups or jugs, it added.
The alert went on to warn that when accidental ingestion has occurred, staff had not always appeared aware of the need to treat it as a medical emergency.
It said that NHS England had been informed of an incident where a patient died after ingesting potassium permanganate.
“Whilst this death remains under investigation, analysis of the National Reporting and Learning System has identified 43 incidents in the past three and a half years where potassium permanganate tablets have been ingested orally by patients,” the alert stated.
“Although none of these incidents were reported as causing severe harm or death, any later effect on the patient was not always clearly described,” it added.