Patient Safety – I just don’t understand it!

Last week NHS England issued a Patient Safety Alert – a stage one warning. Risk of death or severe harm due to inadvertent injection of skin preparation solutions. The basics of it is that people are tipping skin preparation solutions into gallipots and then drawing up the solution in a syringe and injecting them by mistake.

The focus of the alert is the fact that the clinicians were drawing up and injecting saline or contrast media from similar gallipots and this practice should have been eradicated a while ago.

However, why would anyone use a biocide carrying a warning, ‘not for therapeutic application’  for a medicinal purpose in the first place. And why did NHS England not even mention this in their alert?

In fact, why would anyone use a non-sterile solution with poor skin delineation, decanted from a multiuse bottle into a gallipot, wiped on with a swab held by a pair of forceps, with the remaining alcoholic chlorhexidine tipped down the sink n 2015!

I mention this because we have had this safety alert following a signal concerning the risk of fire in the operating theatre, from free alcohol and diathermy equipment. And caustic burns from excess application in preterm infants. And never events with retained swabs.

Wouldn’t it be ‘patient safe’ to use a sterile, single use, controlled release, closed system, licensed medicinal product when ever appropriate.

It would appear not – in the context of NHS England we should continue using the biocides, but be careful.

I have just concluded, that I don’t understand patient safety.


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