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Coming clean about chlorhexidine

Dr Sophie Haroon, Medicolegal Consultant at Medical Protection, recalls some major claims involving the use of chlorhexidine and looks at how they can be prevented.

Surgeon in operating theatre

Introduction

It is well known that preoperative skin antisepsis is crucial to prevent surgical site infections. Guidance already exists on the options for antiseptic skin preparation1. Alcoholic chlorhexidine has gained much traction for use across a variety of surgical procedures2,3, but for something as routine as skin cleaning, Medical Protection has seen a range of claims involving chlorhexidine. These are presented below, including the key risk factors of chlorhexidine that private clinicians need to be aware of.

Recent chlorhexidine claims we have dealt with


Wrong product

Alcoholic chlorhexidine is one of many factors in a surgical fire. However, its most notable role is when aqueous chlorhexidine is requested and instead alcoholic chlorhexidine is provided. This confusion typically arises when both solutions being used in the same theatre are the same colour – usually both being pink. If the wrong solution is picked off the shelf to be poured out and the decanting bottle is not properly checked, the indistinguishable solution applied to the patient is not actually what has been requested. This only becomes apparent when there is an unexpected flame with the potential to cause burns to the patient and any staff nearby.

Incomplete evaporation

Another cause of an alcoholic chlorhexidine-related fire is when its drying time is insufficient. Alcoholic fumes persist and again form a fuel source where a disastrous outcome can ensue.

Allergies and side effects

Chlorhexidine contact allergy has a prevalence of 0.47-1%4,5. Patients have suffered cutaneous reactions to anaphylaxis from the application of chlorhexidine even when this has been a documented allergy. Despite the prevalence listed above, many consider chlorhexidine allergy is under-recognised6. Chlorhexidine is not a benign product and can cause unbeknown side effects.

Learning points

Chlorhexidine use is susceptible to active (individual) and latent (system) errors. A range of mitigation measures are required to address these.

Staff education

This encompasses everything from fire awareness and an understanding of the flammability of chlorhexidine (especially when direct diathermy is involved or due to fume accumulation and hence why evaporation is important), to the risks of pooling under drapes, tourniquets, diathermy return plates, near ECG or other electrodes, to the variety of products on the market, how they appear and how they may be indistinguishable.

Checking the product

Like any medicinal product, checks by appropriate staff need to be undertaken on the product and its expiry date.

Procurement

Where possible, theatres should procure different coloured solutions to help facilitate distinguishing between those that can be of the same colour but different products . Alternatively, a completely different means of delivering one sort of product could be obtained, eg. single use disposable closed applicator system for alcoholic chlorhexidine.

Procedure

Competent persons should undertake skin preparation. This involves allowing sufficient drying time for the alcohol to evaporate, watching out for pooling, not using excess solution, wiping off any that happens to be in excess, checking areas for excess before applying occlusive dressings, and removing soaked gowns, drapes etc before diathermy.

Checking the patient

Like any medicinal product, patients should be asked if they have any allergies to chlorhexidine. These should be appropriately recorded, staff made aware, and alternatives used.

Counsel

Consider advising patients about the side effects of chlorhexidine prior to use and documenting their acceptance to proceed with it with this knowledge.

Documentation

Record which type of antiseptic was used, when, where, and by whom, so that if anything untoward arises, an investigation is better facilitated.

Summary

Chlorhexidine use in skin antisepsis is ubiquitous but not without side effects or even disastrous consequences7-9. Chlorhexidine-related claims seen by Medical Protection are not novel, instead reflecting those seen by others9. However, they serve as a reminder of the active and latent errors that can arise even in routine procedures which require many lessons to manage them and promote patient and staff safety.

Further learning

Unfortunately mistakes do happen. Some will be minor, others more significant. To support our members to navigate an adverse outcome and reduce the likelihood of a claim we provide virtual workshops on a range of topics at no extra cost. Find out more

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