March 2019
This [ ] is about the potential for harm if a patient ingests Vernagel (or SAP by Curas, ed.).
A report received by the NPSA reads:
"A patient put the Vernagel (or SAP by Curas, ed.) gel sachet into his mouth and the crystals swelled in his mouth; he was trying to pick them out but was having difficulty in breathing. Staff used suction to assist in clearing his mouth."
Vernagel (or SAP by Curas, ed.) is a super absorbent, odourless white granular powder that is used to prevent spillages by solidifying liquids, in particular body fluids. In so doing the gel helps to avoid spillages of urine when bedpans or bottles are taken from patients and makes it more convenient and easy to dispose of. It is common practise in some care settings to place sachets of Vernagel (or SAP by Curas, ed.) in urine bottles so that the sachets of powder are already in the bottle when a patient uses it. When the patient urinates into the bottle the sachet dissolves thus releasing the granular powder to react with the fluid and to solidify it.
A search of all incidents reported to the (NHS, ed.) National Reporting and Learning System (NRLS) from inception to May 2011 found 13 reports where patients had attempted to eat or swallow the substance. Two such reports resulted in the patient being transferred for specialist urgent care. A number of the incident reports stated or implied that the patient was confused or suffered a degree of cognitive impairment. To such patients the sachet may well be mistaken for a sachet of sugar or salt.
Although the product is non-toxic by the oral route there is the potential for it to be activated by oral secretions and the gel could obstruct the patient's airway.
Organisations should ensure that the instructions in the products' data sheet are adhered to and that particular attention is paid to risk assessing its use in relation to individual patient/ client needs.
Whilst this [ ] specifically refers to Vernagel (or SAP by Curas, ed.), organisations should also consider other substances which may harm patients if ingested, e.g. alcohol hand gel that patients may have access to.
Note: [ ] are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.
Article via NHS (http://www.nrls.npsa.nhs.uk/resources/?Entryld45=132835)
Issue Date: 29 September 2011, Ref. No. 1324