Errors often occur in the prescribing, preparing, administering and monitoring of intravenous phenytoin (NHS Improvement 2016). Following two fatal incidents involving injectable phenytoin, with contributing factors such as wrong weight estimation, a disregard for existing phenytoin prescriptions and confusion about the final concentration, an alert was issued by NHS Improvement in 2016.

This article explores research into the use of injectable phenytoin and why adverse events occur when it is used. The article will inform nurses and doctors who work with children in acute settings about the risks associated with using injectable phenytoin and implications for practice on how to negate these risks. Applying this knowledge to nursing practice can result in reduced adverse events, and a safer and more effective care environment.