Safety alert after patients injected with antiseptic solution

NHS England has issued a patient safety alert after patients were harmed when they were injected with skin preparation agents

NHS England has issued a patient safety alert to highlight the risk of death or severe harm caused by staff mistakenly injecting patients with skin antiseptic solution.

The alert follows three incidents and one near miss reported via the National Reporting and Learning System during the past three years.

The incidents happen because the antiseptic solution is placed near the intended substance for injection, often in unlabelled containers.

In one case chlorhexidine, a skin antiseptic, was injected instead of X-ray contrast media during a lower limb angiogram, resulting in a leg amputation. Both substances were in unlabelled gallipots.

In another incident a patient having renal dialysis had a line flushed with chlorhexidine, used to disinfect from a gallipot instead of saline solution. A separate near miss followed a mix-up involving chlorhexidine and X-ray contrast medium, even though the two were on different trollies.

The alert states: ‘Organisation need to take all appropriate actions to improve safety, including ensuring that any skin preparation solutions are removed from the environment before an invasive procedure begins.’

All organisations providing NHS-funded care must circulate the information to staff and consider if immediate action needs to be taken to reduce the risk of incidents occurring by July 7.

To read more, go to the NHS England website

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