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Catching Canaries – improving safer use of gentamicin across the network

Gentamicin is a widely used antibiotic but has the potential to cause renal and ototoxicity with an estimated 17,000 patient safety incidents reported over the past 3 years. Catching Canaries wants to collaborate to learn, implement and test improvement, while developing QI skills in the antimicrobial stewardship workforce

Read comments 46
  • Idea
  • 2018

Meet the team: #CatchingCanaries


  • NHSI AMR Project Leads - Emma Cramp, Philip Howard
  • Seeking passionate collaborators - thanks to those organisations who have expressed interest in participating


  • Gentamicin is widely used to treat infection in all acute care settings, and is a toxic drug that has the potential to cause severe harm – renal and ototoxicity

  • Implementation of electronic prescribing systems has been associated with reports of  additional gentamicin associated patient  harm, and NHS strategy is to increase the adoption of e prescribing systems

  • The UK Antimicrobial Resistance (AMR) strategy is driving reductions in broad spectrum antibiotic use, with greater use of agents such as gentamicin anticipated

  • Gentamicin is already is a recurring NRLS reported incident causing severe harm and/or death, but there has been no shared learning about how to reduce risk of harm, and it is estimated hospitals in England reported at least 17,000 gentamicin incidents over the last 3 years

  • The NHS Improvement AMR leads are concerned as this feels like a perfect storm – more gentamicin usage anticipated, increased implementation of e-prescribing while no improvement activity seems to be reducing the risks of harm currently reported

What do canaries have to do with this? Well – the low harm incidents we know are frequently reported, and may not be used to improve practice, are the canaries. If we capture and learn from them we can figure out how to improve, and share that improvement across existing networks.


  • The Catching Canaries flock has fledged and we now have a great team with clinical and medication safety experts, data experts and a very impressive QI training team from  We will be linking into the existing NHS  infection networks and medication safety networks to collaborate with hospitals who want to join the initiative. If your Trust is interested leave a comment before 20th June when this page closes. We anticipate working with a network of up to 20 Trusts.


  • Learning – capturing the extent of gentamicin incidents and identify the drivers that led /could have led to harm

  • Identify what improvement approaches have been implemented and what success and failure looks like

  • Design new improvement approaches if required
  • Test and evaluate – using QI methodology to test out known success strategies in other hospitals and new approaches where appropriate to identify successful improvement models to spread

  • Improvement – key to this initiative is the development of QI culture and skills within the AMR / medication safety networks

  • Each Trust representative will join the #CatchingCanaries improvement network which will meet 5 times over the 12 month project period (and continue afterwards we hope) to share and learn together working to plan, develop and implement an improvement programme suited to the Trust agenda. The CatchingCanaries experts will support and enable this peer network and provide expert support throughout
  • Spread  – the improvement that works with the aim of driving future wider adoption and spread at pace via the existing AMR / medication safety networks


  • March 2019 to Feb 2020

Key outputs

  • Identify the local and collective drivers for the current level of gentamicin harm / potential for harm

  • Learn what improvement systems are in use within the network and successfully reducing the potential for harm

  • Share within the peer network and test implementation in other organisations

  • Identify / develop and test successful risk reduction strategies, and demonstrate how they work

  • Increased workforce QI skills and culture, practice and passion while doing so

  • Reduction in future gentamicin harm is an ambition but the small numbers at individual Trust level mean this cant be used as an outcome measure in the project timeframe. So outcome measures will relate to the local improvement model. We will be testing out the #plotthedots approach as well

  • Improvement offer to spread widely via networks – in particular AMR and medications safety networks  and via AHSNs

  • Evidence generated to inform NHS AMR and patient safety policy

Interested in joining in? Leave a message for Elizabeth Beech



How you can contribute

  • We have had some great help from Q since posting this, but are still wondering if any Royal Colleges interested in joining this project team?
  • We plan to use the existing infection networks and medication safety networks to recruit hospitals to join the initiative - any Q interested?
  • Has anyone already reduced gentamicin incidents? What did this involve? What worked?

Further information

20180619 Catching Canaries Outline Plan (DOCX, 17KB)


  1. Thank you to everybody who supported the Catching Canaries bid, which sadly did not get make it to the next selection. So many organisations wanted to join in - clearly its a real improvement challenge and a big safety concern. Catching Canaries will consider alternative approaches to move forward, so keep the comments coming while QExchange site remains open, and/or send me a message via Q

  2. Catching Canaries have submitted their application and a big THANK YOU to everybody for the amazing level of interest and support and comments posted above.

  3. I agree Helen and see the reply to Laura's comment above re use of shared decision meeting. It will be really interesting to learn more about this from the initial analysis of Trust incident data in Workshop 1.

  4. Clearly an important area. I note that an early comment was from a patient with complications from Gentamycin. I’m not clear thought about the peer involvement in the project. How for example are you going to make use of the insights of someone with hearing loss from gentamicin in helping clcinican recognise the importance of car being taken in dosing etc?

  5. Guest

    Laura Whitney 4 years, 1 month ago

    Would be happy to be involved.

    A national dosing strategy would be great (although very ambitious!)

    Our audiology department is interested in increasing audiological toxicity monitoring for patients receiving prolonged aminoglycosides and we are currently looking at how to establish this so it would be interesting to feed into a national workstream.

    It's a shame the project is restricted to gentamicin. I understand the rationale for promoting narrow spectrum agents, but increasing levels of gentamicin resistance make use of other aminoglycosides necessary for some Trusts. Using multiple aminoglycosides, sometimes with different dosing/monitoring requirements, obviously increases risk further.

    Laura (St George's Hospital)


    1. Hello Laura - You are very welcome to join and focus on other aminoglycosides! gentamicin was selected due to the existing level of reported potential harm, but the power of QExchange is that the projects are informed by the community. So join us and improve safer use of those other aminoglycosides. Love the work you are doing with audiology screening and I wonder what the shared decision making with patients who have prolonged aminoglycoside use looks like re the side effects too.

  6. Guest

    Caroline Hallam 4 years, 1 month ago

    We would be interested in joining the project here at the Norfolk and Norwich...but couldn't commit to attending meetings in the west country!

    1. Hello Caroline - we have included travel funding in our proposal to support Trust participation so  do stay interested!

  7. I love the canary analogy, such an obvious area of potential and patient harm which your project is seeking to address and the lessons are applicable to many other geographical areas.

    1. Hello Hein and thanks for the comments. This is a national project and not a west country project, although the QI workshops will be delivered in Gloucester. We have Trusts interested from different parts of the country including NI so hopefully would have a good geographical mix in the project which strengthens dissemination of the learning as well as improving the QI workforce skills in that area

  8. Guest

    Astrid Gerrard 4 years, 1 month ago

    I agree with the many points made in the discussion so far and would be more than happy to support/ involves with the project. I think Hazel Parker's point on standardising practice nationally, if at all possible, is a very valid step towards improving patient safety and rationalising efforts from many hospitals. Astrid Gerrard, Antimicrobial Stewardship Pharmacist, Worcestershire Acute Hospitals

  9. Guest

    Hazel Parker 4 years, 1 month ago

    Sounds an interesting and important project; we are keen to be involved.  Is there any will to develop an national guideline so juniors do not have to prescribe/use it a different way each time they change trust?!

    Best wishes, Hazel (Exeter)

    1. Hi Hazel, Catching Canaries is aiming to use a nation wide peer approach to improving at a local level, with each Trust identifying where to start to improve (Workshop 1 will deliver the support to do this from local incident data), and the project will support this by QI skills development via the workshops. So it may be some Trusts work on a similar improvement idea (power of collaboration) or all take a different approach. Either way the peer network will be able to contribute to all the improvement activity and there may be a great national offer at the end - as we dont know what improvements work this remains to be discovered, and shared

  10. Guest

    Rakhee Patel 4 years, 1 month ago

    Fantastic initiative and one we would love to be involved in.

    Rakhee Patel

    Lead Antimicrobial Pharmacist Dartford and Gravesham NHS Trust

    1. Thank you for posting support Rakhee - there seems to be lots of Trusts keen to participate in this project which does demonstrate this is a widespread issue and a peer network approach led by the Q community may be a great way to support improvement at scale

  11. Hello Shahzad and thanks to your colleagues at UHB for the email about joining this project. I know your Trust have an excellent QI culture in the infection team and we would love the Trust to join this project and share that QI expertise at the same time

  12. Guest

    Kevin Frost 4 years, 1 month ago

    Hi,  Another antimicrobial pharmacist here via UKCPA - most regions have antibiotic pharmacists groups which would help support/promulgate your work.  Us in Yorkshire and Humber have already done QI work on gentamicin as individual Trusts and regionally.

    1. Hello Kevin - yes we do plan to use the infection networks to disseminate the learning from this project - maybe even the improvement bundles if that is what is produced. The Catching Canaries team have a Y&H representative in the team and he commented about the improvement activity in that Region so we hope to capture and learn from that also.

  13. Guest

    Syed Anas Giloani 4 years, 1 month ago

    Witnessed far too many problems with Gentamicin prescribing and monitoring across several Hospitals as an Antimicrobial Pharmacist. Currently we are developing Gentamicin and Vancomycin specific prescriptions to embed in our upcoming electronic prescribing system at The Dudley Group NHS Foundation Trust West Midlands.

    Elizabeth we would love to be a part of any improvement initiative.

    Syed Gilani Advanced Pharmacist Antimicrobial Therapy

    The Dudley Group NHS Foundation Trust West Midlands

    1. Hello Syed - hopefully we can learn from your experience with implementing the e-prescribing system you mention - whats the plan to capture and potential incidents?

  14. Guest

    Samantha Lippett 4 years, 1 month ago

    We have experience of implementing safer gentamicin prescribing initiatives following a drive to reduce co-amoxiclav due to high CDI numbers. We also have some work auditing the impact of greater gentamicin use in the elderly with respect to renal toxicity. I also have some slightly maverick research ideas which may mitigate the renal toxicity risk. Would be a pleasure to share our learning Nationally and be part of a National project to further this very worthwhile piece of work particularly given the pressure of the CQUIN to increase Access category antibiotics.

    Samantha Lippett

    Lead Antimicrobial Pharmacist

    Brighton & Sussex University Hospitals NHS Trust

    1. Hi Samantha - a key element of the Catching Canaries project is about the peer network, and it would be great to learn from your experience with safer gentamicin improvement. If we get funded you are very welcome to join the project

  15. Guest

    Shahzad Razaq 4 years, 1 month ago

    Agree with other posts on here, that this is a fantastic initiative and one that we would like to be a part of.

    1. Hello Shahzad and thanks to your colleagues at UHB for the email about joining this project. I know your Trust have an excellent QI culture in the infection team and we would love the Trust to join this project and share that QI expertise at the same time
      Reply 0

  16. Guest 4 years, 1 month ago


    I spotted this on the UKCPA PIN forum. I think its a really worthwhile project as it is such a complex subject and it would be really useful to measure improvement processes carried out by individual trusts as there is great potential for shared learning to improve patient safety with this medication. I'm currently running a Gentamicin Qi project in my hospital in Dublin - happy to feed back when this is complete although not an NHS trust. Also, although it may not be in the scope of the project but I think it would be great to get some clarity on infusion times for once daily dosing and the significant variance in recommendations from different manufacturers and standard references like the BNF, Medusa, injectable drugs guide etc.

    Kind regards


    Tallaght Hospital, Dublin, Ireland.

    1. Hello Deirdre and thanks for sharing your improvement work with us. This is all about peer support for improvement in patient safety so it would be great if we could tap into each others programmes

  17. Guest

    Tejal Vaghela 4 years, 2 months ago

    At West Herts we have tried numerous initiatives to improve gentamicin prescribing and monitoring -some success and some failures. Gentamicin is widely use and a very useful resource especially in times of increasing resistance. I feel this project will be useful and will be very interested in following the outcome.

    1. Thank you for comments Tejal and would your Trust be interested in joint the Trusts if this gets funded? Would be really useful to share those failures and successes

  18. Guest

    Annie Joseph 4 years, 2 months ago

    With increasingly limited antibiotic options due to resistance and shortages,  we are becoming more reliant on aminoglycosides routinely in hospitals. It would be really useful to include aspects assessing the impact / potential impact of e-prescribing. As a hospital that is not yet near to eRx introduction it would be great to learn how others have incorporated this into improvement in aminoglycoside use. Another area is assessing the impact of different approaches to dosing and therapeutic drug monitoring, as I think we probably cause harm by underdosing and overdosing - although toxicity is the more acute concern,  under treatment of sepsis also carries significant harm. I would be interested in following the outcomes of this proposal.

    1. Thanks Annie and would your Trust be interested in joining if we get funding?

  19. Guest

    This is a great initiative as there are so many patients affected. Gentamicin is a very useful antibiotic if it is used safely. At the University Hospitals of Leicester, we have numerous gentamicin prescriptions to aid prescribing and monitoring but they haven't been evaluated therefore we do not know the impact that these have had on our incident rates. This would be a very useful exercise.

  20. Guest

    Philip Howard 4 years, 2 months ago

    The Yorkshire and Humber Antimicrobial Pharmacists group developed a standardised chart for the region a number of years ago to reduce errors from unfamiliarity in prescribing. This was based around the Buabeng paper (link below). Whilst it was tweaked by hospitals, it is largely the same. Unfortunately, there has been no formal evaluation (qualitatively or quantitatively) on its impact.   I would be keen to see this project move forward. Buabeng paper on EID Gentamicin

  21. Delighted Vicky Collins has joined the team


  22. Guest

    Paul Fitzsimmons 4 years, 2 months ago

    Hi Elizabeth

    Agree this is a national issue and seems to be a growing issue locally. Happy to support in any way I can, agree with Kate’s comment above that measuring the impact will be an interesting challenge.




    1. Hi Paul and good to have your support. As replied to Kate, we do not plan to measure incident numbers as a primary outcome as not enough scale of time to pick up improvement in this project, but do intend to measure the improvement processes Trusts introduce locally; so this may vary with each Trust. A key objective of this project  is to develop the QI culture and skills with the infection management workforce and its great that Andrew Seaton has joined the team bringing that workforce development expertise

  23. Elizabeth, Not sure what the QI methodology is that you refer to in your project page but the following document is a very good description of the QI process. If you decide to do any process mapping during your project I would be keen to help. Regards Tom

    1. Hello John and thanks for the interest and links. At present the QI methodology is not specified as it will depend on individual Trust - it may be process mapping is the approach for one Trust while PDSA cycles may be the appropriate approach for another. At the moment there are many incidents but no collective sharing and learning, so there is limited knowledge of cause, and no 'what works' model to share and implement with a QI toolkit attached -yet. Maybe this project should rename as the Chicken or the Egg.

      So if process mapping is required I will count you in - many thanks.

  24. I support this project and having looked at injectable safety issues with gentamicin previously appreciate this is a highly complex issue. It aligns with the WHO 'Medication without Harm' global patient safety challenge and sepsis/AKI initiatives.

  25. Hi Elizabeth, would be very happy to work through some of the practicalities of data access and thematic analysis as part of the Patient Safety Measurement Unit work.  Would be interested to hear what the general measurement strategy is for this (with obvious links to Making Data Count!) given that incident reports generally aren't suitable for measuring impact over time.

    All the best!


    1. Thanks Kate. The data measurement would be aligned to local improvement approaches (which the project will identify from learning from what is working now or from innovation) and the workforce learning how to do this well.

      This is not going to be counts of safety incidents - as you say too few too infrequently for a single site over a months timeline. And safety incidents are already reported and will continue to be so via usual national reporting.

      It would be great to work with you on the measuring improvement approaches and the initial thematic analysis

  26. Hi Elizabeth, a national review of these incidents and fact-finding exercise of QI improvement in this area is definitely warranted. I have shared your submission with a member of the NI antimicrobial pharmacist network as this is very topical, we've been having very similar conversations recently in NI about this and other aminoglycosides and the need for QI in this area.

    1. Excellent and should this get funding they are welcome to join the CatchingCanaries peer network

  27. Hi Elizabeth, this as you say is a national problem and it would be great to see a UK wide initiative involving all regional antimicrobial networks to improve safety in this area. I'd be interested to hear more about what your idea as the management of gentamicin and other aminoglycosides has certainly been a long-running safety issue.

    1. Hi Angela. I have updated the content with more details, and would be delighted if you were to join the Catching Canaries project.

  28. Hi Elizabeth

    Great to see that you have put forward a project.  I have had so much of this medicatio as a teenager i now suffer from hearing loss, along with the toxicity issues its often not made up correctly or diluted enough to prevent tissuing of lines. I'm glad you are taking this on as a challange and wish you all the best with it. I will be your first supporter for the idea.

    1. Thanks Jono and great to have your support. Please pass constructive comment too once I post the details too


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