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

    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 
    Read more...
  • Eye drops and HIV medication reaction

    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). 

    Read more...
  • Ranitidine and breast disorders

    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.

    Read more...
  • Rivaroxaban (Xarelto ▼) drug administration error

    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).

    Read more...

About a medical device

  • Blood gas analyser

    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.

    Read more...
  • Skin wipes allergic reaction

    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. 

    Read more...
  • COPD medicine and choking

    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. 

    Read more...

Non-prescription product reported

  • Bonjela gel and swollen tongue

    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.

    Read more...
  • Corn plasters and skin ulceration

    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.

    Read more...
  • Gaviscon Infant and Constipation

    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.

    Read more...

Patient reported

  • Contraception Yasmin and hair loss

    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.

    Read more...
  • Labetalol and nipple pain

    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.

    Read more...
  • Perindopril and Raynaud's phenomenon

    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. 

    Read more...
  • Sayana and muscle loss

    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.

    Read more...

Healthcare professional reported

  • Nexplanon contraceptive implants

    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. 

    Read more...
  • Phacoemulsification handpieces cataract surgery

    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 
    Read more...
  • Posaconazole medication error

    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. 

    Read more...

Prescription-only product reported

  • HIV medicine and Fluticasone reaction

    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.

    Read more...
  • Phenytoin and purple glove syndrome

    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.

    Read more...
  • Steroids and red skin syndrome

    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. 

    Read more...