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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 5/26/2015 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board
This alert addresses the ongoing patient safety incidents that occur when solutions intended for topical use are inadvertently injected. In most cases the cause of the error was due to the use of “open systems” where two solutions are poured into open containers such as gallipots; one of the solutions is intended for topical use while the other is for injectable use. The containers are not labelled and the solution is given by the wrong route. A common practice setting for these incidents has been where invasive or interventional procedures are carried out. Three incidents are described. Two incidents involved severe harm from confusion between 2% chlorhexidine and x-ray contrast media in circumstances where both substances were in unlabelled gallipots (one during a lower limb angiogram and resulting in leg amputation, and one during a pacemaker insertion resulting in cardiac arrest and resuscitation). The third incident involved a patient undertaking renal dialysis with assistance from healthcare staff; the line was flushed with chlorhexidine from a gallipot instead of the intended saline solution and the patient became unwell but apparently recovered. A near miss also involved chlorhexidine and x-ray contrast medium, and occurred despite the skin preparation being on a separate trolley. Recommended actions to mitigate the recurrence of such incidents are provided.

Additional Details

Medication/Gas/Fluid:
skin cleansing antiseptic solutions, chlorhexidine 2%, saline, x-ray contrast media

Communication
  1. Circulate this alert to all relevant staff.
  2. Share any information on areas of clinical practice where use of open systems for injection appears to have persisted (and why), any learning from local investigations, and any locally developed good practice resources by emailing: patient. safetyenquiries@nhs.net
Rules / Policies / Procedures
  1. Identify if invasive procedures involving injection alongside skin preparation are taking place in circumstances where unintended injection of skin preparation solution has or could occur.
  2. Consider if immediate action needs to be taken locally, and ensure that an action plan to reduce the risk of incidents occurring is underway if required.

Risk of death or severe harm due to inadvertent injection of skin preparation solution