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Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear (30 October 2017)

Summary

Rob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed.

Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world.

There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost. 

Content

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Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear (30 October 2017) https://www.youtube.com/watch?feature=youtu.be&v=q_qLjfmDSBY&app=desktop

Edited by Patient Safety Learning

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Derek Malyon

Members

What an important subject. No comments and no solutions from readers.

"Antiseptic solution injected into her epidural."

On inspection these medicines etc. have a barcode differentiating them.

The patient's care plan shows on-screen in front of health worker and patient the allowable medicines for epidural. In error the antiseptic barcode read and error detected using the software-checklist then alarmed. The consequences of the human error reduced 10,000 fold.

Check out: Ward-Patient eQMS with Error Recovery Protocols.4.pdf

 

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