NHS England: Inadvertent use of 100% alcohol on ocular surface (24 July 2025)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident related to a surgical procedure to the eye which resulted in patient harm from 100% alcohol being applied to the cornea without the solution being diluted to the desired lower strength.

Patients undergoing collagen cross-linking procedures to the eye, require removal of a section of corneal epithelium by applying 18% or 20% alcohol to the cornea. When unable to procure a pre-diluted solution, practice was to dilute 100% alcohol to achieve the desired strength. In the reported cases the dilution process was inadvertently omitted, resulting in 100% alcohol being applied to the cornea, causing damage to the ocular surface. 

NHS England worked with The Royal College of Ophthalmologists (RCOphth) Quality and Safety Committee who used the findings to publish a Safety Alert.The Safety Alert asked members to evaluate the use of alcohol during corneal cross-linking surgery and whether suitable 18% or 20% alcohol preparations could be sourced from a specials manufacturer.

The recommendations made by RCOphth were communicated to the Medicines Safety Officers network across NHS providers.