A safety alert has been issued by NHS England warning against accidental injection of skin preparation solution, after a string of errors that have resulted in severe harm to patients.
Since 2012, three incidents have occurred following the use of gallipots to store medication for injection.
This is despite guidance stipulating injections must only ever be drawn up from the source bottle or ampoule directly into labelled syringes.
In two cases, clinicians confused 2% chlorhexidine with the intended x-ray contrast media – when both were stored in unlabelled gallipots.
“The practice of preparing medication for injection using gallipots may have persisted in some areas carrying out specific interventional procedures”
One of these incidents occurred during a lower limb angiogram, resulting in leg amputation. The other happened during a pacemaker insertion and the error caused cardiac arrest leading to resuscitation.
Another incident happened when a patient was carrying out renal dialysis with help from healthcare staff. Instead of saline solution, the line was flushed with chlorhexidine from a gallipot, causing the patient to become unwell.
Meanwhile, a near miss also occurred when chlorhexidine and x-ray contrast medium were confused, despite the skin preparation being on a separate trolley.
The alert states: “The settings where these incidents occurred suggest that the practice of preparing medication intended for injection using gallipots may have persisted in some areas carrying out specific interventional procedures.”
“We are working with relevant royal colleges…to understand if any additional advice is required for specific procedures”
“We are working with relevant royal colleges and specialist professional organisations to understand the reasons for this, and to understand if any additional advice is required for specific procedures,” it adds.
The safety alert warns there is a risk of death or severe harm if skin preparation solution is injected and urges organisations to ensure the solutions are removed from the environment before an invasive procedure begins.
The alert also calls on organisations to identify where “open systems” – such as the use of gallipots – for injectable medication have continued to be used and to take action to improve safety.
It is not the first time an alert of this nature has been given. Similar alerts were issued in England in 2007 and reinforced in 2010, stating that “open systems” should never be used to contain medication prior to injection.