Do Not Use a Syringe for a Topical Product – A Focus on Chlorhexidine Disinfectant Solutions

This bulletin provides recommendations to eliminate the unacceptable practice of using syringes for topical products. To prevent inadvertent injection of topical solutions, hospitals should ensure topical solutions are available in ready-to-use labelled formats. They should also develop separate, easily differentiated processes for the storage, preparation, and handling of medications intended for topical application and those intended for parenteral injection.
Key Words:
- Chlorhexidine

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INTRODUCTION

To prevent inadvertent injection of topical solutions, hospitals should:

  • • Ensure topical solutions are available in ready-to-use labelled formats.
    • – For topical chlorhexidine, chlorhexidineimpregnated swabs are an ideal choice; an alternative is a visually distinct tinted solution.
  • • Develop separate, easily differentiated processes for the storage, preparation, and handling of medications intended for topical application and those intended for parenteral injection.

The practice of drawing a medication intended for topical use into a syringe is unacceptable. Most syringes are intended for parenteral administration and pose a risk for a substitution error and/or inadvertent injection.1 This practice has resulted in potentially deadly and preventable medication safety incidents.2 Continuing concerns related to inadvertent injection of chlorhexidine solution intended for topical application serve as a reminder of the need to review practices in patient care areas such as the operating room, where both topical and injectable solutions are used.3 ISMP Canada has previously made specific recommendations concerning the use of topical epinephrine in the operating room, and these recommendations have informed subsequent standards4 and the Never Events for Hospital Care in Canada.5

The risk for inadvertent wrong route injection exists for any topical solution that is used in an environment where syringes are present.

The literature contains reports of medication incidents from several countries, some fatal, involving the inadvertent parenteral injection of chlorhexidine disinfectant solution intended for topical application.6-9 In some incidents, both the chlorhexidine disinfectant solution and the solution intended for injection (e.g., a local anesthetic, an injectable medical dye) had been poured into open, unlabelled bowls in the operating room; the incorrect solution was then drawn up into a syringe and administered parenterally. Previous recommendations from ISMP Canada have warned against the use of open containers to hold medications intended for injection.2

Practitioners and hospitals are urged to proactively review the management of solutions intended for topical application. ISMP Canada has shared its concerns with the Medication Management Technical Committee of the Health Standards Organization (HSO), a global standard-setting organization. Other standard-setting organizations are encouraged to consider ISMP Canada’s recommendations to prevent harm or death due to inadvertent injection of topical products

RECOMMENDATIONS

Hospital Procurement

By implementing the following recommended system safety enhancements, organizations can reduce preventable inadvertent injection of topical chlorhexidine products:

  • • Ensure that products are in ready-to-use formats. Chlorhexidine-impregnated swabs should be the only form of chlorhexidine available for skin disinfection in the procedure area, where available.10
  • • If chlorhexidine solution must be used (e.g., because swabs are unavailable), only procure formulations that are tinted with a visually distinct dye (Figure 1), to provide a visual cue that the liquid is not to be injected.10 Avoid supplying a clear chlorhexidine solution that could be mistaken for a product intended for parenteral administration. –
    • Note: Use of a tinted product should be accompanied by a check that the patient is not allergic to the dye used in the product.

Clinical Management and Staff

System interventions should be designed to segregate use of products for distinct purposes. Until optimal product designs for safety are in place (e.g., availability of products in ready-to-use formats, use of unique connectors for different routes of administration), the following strategies can help mitigate the risk of inadvertent injection of topical products:

  • • Do not use a syringe to draw up, hold, or apply a solution intended for topical use.
    • – Note: Although a small selection of topical syringes may be available, topical medications should only be administered with a distinct topical applicator.
  • • Develop separate, easily differentiated processes for the storage, preparation, and handling of medications intended for topical application and those intended for parenteral injection.
    • – Ensure that the word “TOPICAL” appears on the label of any container used to hold a solution intended for topical application.1,2,11
    • – Perform skin preparation before introducing equipment and injectable solutions to the sterile procedure area.10 This ensures that skin preparation solutions, such as chlorhexidine, can be removed and kept separate from injectable solutions used during procedures.
    • – Label every syringe and container with its contents.11 Sterile preprinted labels are available to facilitate labelling in sterile areas, including operating rooms. Discard any unlabelled syringes and containers.12

The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and Healthcare Excellence Canada (HEC). The goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada.

Funding support provided by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

The Healthcare Insurance Reciprocal of Canada (HIROC) provides support for the bulletin and is a member owned expert provider of professional and general liability coverage and risk management support.

The Institute for Safe Medication Practices Canada (ISMP Canada) is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada’s mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives.


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