Skip to main content Accesibility Help

Medication patient safety incidents linked to rapid tranquillisation: one year's data from the National Reporting and Learning System

  • James Innes (a1) and David Curtis (a2)

Rapid tranquillisation (RT) is a procedure that carries both medication and non-medication related risks. It has also recently been targeted by the NHS Litigation Authority, with an entire risk management standard devoted solely to this intervention. In this study, we aim to quantify the risk associated with RT, by looking at medication patient safety incidents (PSIs) reported by all NHS healthcare providers over the course of one year.


Medication PSIs relating to RT that occurred between 1 August 2010 and 31 July 2011 were extracted from the National Reporting and Learning System (NRLS) and analysed.


The number of PSIs extracted from the NRLS was low and no incidents related to adverse effects or harm encountered post administration of RT. These results are not generalisable as this study describes one search strategy of what is a fragmented system for reporting RT related PSIs.

Conclusions and implications for clinical practice

This study indicates that the task of examining RT related PSIs in their entirety would be neither easy not simple. There needs to be a more relevant, reliable and robust system for reporting incidents related to RT.

Corresponding author
Correspondence to: James Innes, Pharmacy Department, Mile End Hospital, Bancroft Rd, London, E1 4DG. E-mail:
Hide All
Blofeld, J., Sallah, D., Sashidharan, S., Stone, R., Struthers, J. (2003) Independent Inquiry into the Death of David Bennett. Cambridge: Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 75 pp.
Innes, J., Iyeke, L. (2012) A review of the practice and position of monitoring in today's rapid tranquillisation protocols. Journal of Psychiatric Intensive Care. 8(1): 1524.
Innes, J., Sethi, F. (2013) Current rapid tranquillisation documents in the UK: a review of the drugs recommended, their routes of administration and clinical parameters influencing their use. Journal of Psychiatric Intensive Care. 9(2): 110118.
Joint Committee on Human Rights (2004) Joint Committee on Human Rights - Third Report: Deaths in custody. House of Lords and House of Commons. HL 15-I/HC 137-I.
Loynes, B., Innes, J., Dye, S. (2013) Assessment of physical monitoring following rapid tranquillisation: a national survey. Journal of Psychiatric Intensive Care. 9(2): 8590.
NHS Litigation Authority (2012) NHSLA Risk Management Standards 2012-13: for NHS trusts providing acute, community, or mental health & learning disability services and non-NHS providers of NHS care. NHS Litigation Authority.
NHS Protect (2012) Violence Against NHS Staff Statistics 2011-12. NHS Business Services Authority.
National Institute for Health and Clinical Excellence (2005) Violence: The short term management of disturbed and violent behaviour in inpatient psychiatric settings and emergency departments. Clinical Guideline 25. NICE, 83 pp.
Police Complaints Authority (2002) Safer Restraint: Report of the conference held in April 2002 at Church House, Westminster. London: PCA.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of Psychiatric Intensive Care
  • ISSN: 1742-6464
  • EISSN: 1744-2206
  • URL: /core/journals/journal-of-psychiatric-intensive-care
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed