NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Administration error: 48 hourly IV Gentamicin

There have been recent incidents across GG&C involving 48 hourly IV gentamicin which was prescribed a day in advance and subsequently administered 24 hours earlier than intended.  This may potentially lead to gentamicin toxicity and side effects such as renal impairment/ototoxicity.  We are therefore recommending that all nursing staff, prescribers and pharmacists be aware to try and minimise the risks of this happening.

Learning/good practice points:


  • Do NOT prescribe gentamicin more than 24 hours in advance. Patients on gentamicin should be reviewed daily with an assessment of their clinical status, renal function and gentamicin levels.  In most cases there should be no need to prescribe doses in advance.
  • If a patient’s recommended dosing schedule is 48 hourly gentamicin, then, on the date that NO gentamicin  dose is due the prescriber should write the date and “no dose required – 48 hourly dosing” on the gentamicin chart (see example below).

Nursing Staff

  • Before preparing and administering IV gentamicin carefully check the date and time the dose is prescribed. (See example below)

This guidance, including examples, will be included in the therapeutics handbook (currently in the process of being updated).  

(If viewing image on a mobile device switch to landscape)

Gentamicin chart

Please encourage the discussion of this information at local teaching sessions and team meetings.


Published 20/02/18