Patient Safety Alert from HPFT: Memantine titration packs

Hertfordshire Partnership University NHS Foundation Trust (HPFT) has asked us to share some messages relating to incidents of prescribing of Memantine titration packs and administration errors.

  • In one incident, the carer was administering the wrong strength tablet, not realising that the pack contained different strength tablets that had to be given in a particular order.
  • In the second, the carer was administering medication from the titration pack and in addition, was giving tablets from the maintenance dose box.

Staff have been reminded to go through the up-titration and the continuation doses with patient and carer.  In addition, they are post dating the maintenance dose prescription so that it can only be dispensed once the titration pack is almost complete.

Please could community pharmacy colleagues support in reinforcing instructions regarding titration packs at the point of dispensing. Full details are available in the Patient Safety Alert: Memantine titration packs.