Case studies
Our case studies below describe occasions when Yellow Card reports have directly contributed to patient safety.
When a new safety issue is identified following a Yellow Card report:
- relevant warnings will be added to the product information
- advice on how the product should be used may change
- warnings may be given to groups of patients, healthcare professionals or users of the product
Often, safety issues are not linked to a specific medicine or medical device until they are reported to the Yellow Card scheme. Information from Yellow Card reports is considered alongside other safety information.
Reporting can make a big difference in keeping the public safe. Find out more about the Yellow Card scheme, including what happens when you submit a report.
About a medicine
Charcoal and drug interaction
Read more...A hospital pharmacist submitted a Yellow Card report after seeing a woman in her seventies who was taking several medications including:
For a chest infection
- amoxicillin
- clarithromycin
Commonly used to treat heart failure
- candesartan
- bisoprolol
- furosemide
Eye drops and HIV medication reaction
Read more...A hospital pharmacist submitted a Yellow Card report raising his concerns over the interaction between ritonavir and topical corticosteroids. The report was related to a young male who was on long-term antiretroviral therapy (ART).
Ranitidine and breast disorders
Read more...A hospital doctor completed a Yellow Card report about a baby girl suffering from recurring bleeding from both nipples, for one day every few months. As well as this, the baby was taking ranitidine.
Rivaroxaban (Xarelto ▼) drug administration error
Read more...A hospital pharmacist reported that a female patient had been taking 15mg of rivaroxaban treatment, twice daily for a diagnosed deep vein thrombosis (DVT, a blood clot in a deep vein).
About a medical device
Blood gas analyser
Read more...A neonatal ward made a report regarding a number of false results obtained from a blood gas analyser. The cases involved blood samples taken from babies during delivery. Concerns were raised because important treatment decisions could have been made based on these false test results.
Skin wipes allergic reaction
Read more...We received some Yellow Card reports from patients having adverse reactions after touching equipment or surfaces that had been cleaned with Clinel wipes. These reactions varied from skin reactions such as a rash, to anaphylaxis.
COPD medicine and choking
Read more...A woman in her sixties was taking Braltus COPD. Braltus is prescribed in the form of a powder within a hard pill capsule and is taken using a Zonda inhaler.
Non-prescription product reported
Bonjela gel and swollen tongue
Read more...An elderly woman was using Bonjela for tongue pain. After using Bonjela, the woman suffered from a swollen tongue which was so severe that it was considered to be a possible choking hazard.
Corn plasters and skin ulceration
Read more...A podiatric physician (foot doctor) contacted the Medicines and Healthcare Regulatory Agency (MHRA) regarding concerns over medicated corn removal plasters (a medical device) that contained salicylic acid.
Gaviscon Infant and Constipation
Read more...A three-month-old baby boy was prescribed Gaviscon Infant (containing sodium alginate and magnesium alginate) to manage reflux, a condition in which the contents of the stomach come back up into the food pipe.
Patient reported
Contraception Yasmin and hair loss
Read more...After three months of being prescribed contraception Yasmin, a female in her twenties suffered a large amount of hair loss (alopecia). She suspected this might be due to the medicine she was taking, so she checked the patient information leaflet (PIL) found inside the packaging.
Labetalol and nipple pain
Read more...A pregnant woman sent a Yellow Card report about crippling nipple pain that she was experiencing. The pain lasted for about 20 minutes each time. It happened while she was taking labetalol.
Perindopril and Raynaud's phenomenon
Read more...A Yellow Card report was sent in by a man in his sixties who was taking perindopril for high blood pressure. His doctor changed his medicine to another called ramipril but he didn't remember exactly when. Later, he started having a problem where his fingers would become white, get really cold and feel numb during cold weather.
Sayana and muscle loss
Read more...A woman in her thirties received her Sayana injection and then developed a deep hole in her leg in the area where received her injection.
Healthcare professional reported
Nexplanon contraceptive implants
Read more...Nexplanon is a long-acting contraceptive that is inserted under the skin of a woman’s upper arm. To be effective, nexplanon needs to be correctly implanted by someone who is trained.
Phacoemulsification handpieces cataract surgery
Read more...A number of Yellow Card reports have been received about particles found in the eye either during, or after cataract surgery. Investigation into these particles have found that they were from several sources, including:
- Medical instruments
- Packaging
- Debris from previous surgery
- crystallised fluids used during surgery
Posaconazole medication error
Read more...A patient in hospital was prescribed the liquid version of posaconazole but was instead given tablets. The liquid and tablet are in different forms and contain a different amount of medicine; they are therefore not to be swapped with each other.
Prescription-only product reported
HIV medicine and Fluticasone reaction
Read more...A man in his thirties was taking a combination treatment containing cobicistat (Stribild▼) for HIV therapy, prescribed by a genitourinary medicine (GUM) clinic. He also started taking a fluticasone inhaler, which was prescribed and dispensed at his GP surgery. Following this, the patient developed serious side effects.
Phenytoin and purple glove syndrome
Read more...A female patient in her sixties contacted a pharmacist about redness and swelling in her right arm. She was taking phenytoin injections for treatment of a serious epileptic condition. This was later diagnosed as purple glove syndrome.
Steroids and red skin syndrome
Read more...A report was sent to the Yellow Card scheme about ‘red skin syndrome’. To reduce the risk of these side effects, we reviewed all the evidence available, including Yellow Card reports and information published by researchers and other medicines regulators.
