Superabsorbent polymer gel granule ingestion – risks of death and severe harm

Risk of death and severe harm from ingestion of superabsorbent polymer gel granules – national patient safety alert released

NHS Improvement has released a patient safety alert highlighting the risk of death and severe harm through suffocation following ingestion of superabsorbent polymer gel granules. The polymer gel granules are not toxic, however, if swallowed they expand on contact with saliva presenting a risk of airway obstruction. Polymer gel granules are used to reduce spillage onto clothing and bedding from items such as bedpans and washbowls or included within products like urine bottles and vomit bowls or spill kits/Controlled Drug (CD) denaturing kits. They can be used in various formats including loose powder, mats and sachets.

NHS Improvement issued a patient safety alert in 2017 identifying the risk of death and severe harm from ingestion of superabsorbent polymer gel granules. However, following this alert, there were further reports of patient death through asphyxiation; this may be because providers have been relying on local awareness of risk in preference to reviewing their own processes on use of these products. NHS Improvement has now stated actions to be completed by all organisations to protect patients by placing strict restrictions on the use of these products, using them only for exceptional infection control purposes.

Pharmacists and pharmacy teams must:

• Adapt processes to introduce purchasing controls which prevent inappropriate ordering of products containing polymer gel granules (loose powder/mats/sachets)
  • This may include purchases through the pharmacy of such products by private clinics/care homes for use within their organisation
• Ensure that polymer gel products not intended for patient use (such as those used in spill kits and CD denaturing kits) are kept securely and away from patients
  • Pharmacists providing additional private services that may require spill kits such as phlebotomy/coagulation testing services should be vigilant; patients and customers should not be left unattended in consultation rooms holding such products or such products should be removed from the sight of patients

Further information on actions to be taken by other organisations can be found in the national patient safety alert.

 For further information on this or any other query, please contact the NPA Pharmacy Services team on 01727 891 800 or email pharmacyservices@npa.co.uk.

 Produced by the NPA Pharmacy Services team December 2019.