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Alert issued over injecting skin preparation solution


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”

NHS England

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”

NHS England

“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.


Readers' comments (11)

  • I could not believe my eyes reading this. I have never heard of such a thing! OK, I'm not general-trained, having been a psychiatric nurse for nearly 40 years and therefore not having that kind of experience. Clearly it must have been common practice at some point, for the issue even to have been raised and guidance given.

    Can somebody explain why a substance would ever be decanted into an interim container and not drawn up directly into a syringe? Is it to save waste? For example, if you need to give somebody 25mg of something that is only available in 50mg ampoules. And of course, you draw up the full amount and discard the surplus - a waste, perhaps, but safe, and sterile.

    I am truly astonished that a practice so open to error has ever occurred.

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  • Shocking!!!
    As an acute staff nurse I cannot believe this disregard for practice could happen!! In our trust saline and water for injection vials, which are clearly marked are not even allowed to bwe stored side by side!

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  • We take more care with this with injections for animals - I can't believe any competent institution is allowing transfer of IV meds in the first place.

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  • Speechless!!

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  • Pussy

    Words fail me and that's a first!

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  • Don't know if this link will work but if you search 'The Human Factor: Learning from Gina's Story' on Youtube you will find a really heart wrenching video about one of the incidents referred to in the article.

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  • Thank you Anita, the link does work and it is indeed a sobering tale!

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  • I am totally gobsmacked that something like this can occur in the NHS today,What absolute carelessness. Whatever is happening in the nursing profession today.Youve staff nurses sat on their backsides at computers all day. Never bedbath a patient as its below them.Now this!!! I must admit Im not surprised due to the uncaring and obnoxious attitude of some of todays nurses. Thank goodness I'm retired !

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  • I Used Gina's Story during a study day for Perioperative staff in Scotland at RCSEd site on saturday, run by the theatre staff association.

    This appears to be a global problem / issue! An Australian member of our organising team, before this event, discussed a C Section mother left paralysed from waste down, when chlohex skin prep was injected into her epidural space.

    Our study day included a reflective practice session, inviting delegates to share their reactions to a critical incident occuring in the past two weeks!

    A delegate recounted a severe pre-surgery anaphylaxis reaction, not once, but twice in the same patient! Eventually tracked to anaesthetic teams use of chlorhex COATED intra-arterial device.

    Frightening revelation for audience - Stay alert!

    Adrian Jones : Vice President
    The Association for Perioperative Practice

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  • I had a look at Gina's story when I got home. It was shocking.

    What makes this even worse is that I came across an almost identical story, with exactly the same error caused in exactly the same way, from as long ago as 2004, in the USA.

    The outcome for that patient was not exactly the same. She had a leg amputation, too, but subsequently died from multiple organ failure.

    So even at least eight years previously, this was a known and avoidable risk. Just because it was in a different country doesn't make it acceptable that it wasn't known about here.

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