PA PSRS Patient Saf Advis 2005 Dec;2(4):29-31.
Clear Liquids May Place Patients at Risk

Introduction

These reports to PA-PSRS highlight the hazards of using unlabeled or mislabeled clear liquids, such as Domeboro solution, in the provision of healthcare:

A patient noted that the solution in the oxygen humidifier was Domeboro solution instead of sterile water. The container was labeled incorrectly.

A patient accidentally drank a large gulp of Domeboro solution. This was an external treatment for the patient’s foot. Patient thought it was water.

Domeboro solution has been used for more than 50 years in health applications such as swimmers ear, athlete’s foot, foot odor, insect bites, poison ivy/sumac, eczema, skin rashes, herpetic lesions, and wound care.1 When Domeboro powder or tablets are dissolved in water, the ingredients calcium acetate and aluminum sulfate produce a chemical reaction that results in aluminum acetate.2 This acidic astringent solution reduces itching, and soothes and dries weeping wounds/lesions. Ordinarily, the solution is used as a soak with compresses or wet dressings or in a bath. Any unused portion can be stored for up to 7 days in a clean, capped/covered container, at room temperature.1

It is at this point of storage that patient safety may be compromised. Because Domeboro solution is clear, it can easily be mistaken for other clear liquids, if actions are not taken to reduce risks of accidental exposure. Moreover, leaving unused Domeboro solution at the bedside for recurrent soaks/treatments may increase the risk of confusion with other liquids.

Domeboro solution is not innocuous. It can cause irritation, redness, and itching upon skin exposure, resulting in contacting the physician if irritation develops. When in contact with eyes, Domeboro can cause eye irritation: tearing, stinging, reddening, requiring flushing the eyes with water for 15 minutes and contacting a physician. If ingested, it may produce nausea and vomiting, and contacting the regional poison control center or a physician immediately is advised. If inhaled, the person should be provided with fresh air.3

Additionally, there is the risk of aluminum toxicity, particularly in patients with chronic severe renal failure and in preterm infants with underdeveloped renal function.4,5

Symptoms of aluminum toxicity include anemia, dementia, bone disease, impaired neurologic development, encephalopathy in uremic patients, impaired calcium metabolism that can lead to osteoporosis, impaired kidney function, colic, gastrointestinal problems, headaches, liver dysfunction, forgetfulness, extreme nervousness, and memory loss.1,2,5-7

Inadvertent ingestion/inhalation of Domeboro solution may increase the risk of aluminum toxicity, particularly in renal compromised patients. Treatment for toxicity may even require the use of chelating agents to rid the body of aluminum,8,9 which has no biologic role in humans.6

Other Examples

As suggested by the PA-PSRS reports above, both healthcare workers and patients can confuse Domeboro solution with other liquids. However, Domeboro solution is just one example of many clear liquids that are used in healthcare, each of which carries the potential for confusion with another product.

Sources outside of PSRS have reported the following scenarios in which liquids have been confused:

  • A 100 ml bottle of sterile water and an identical bottle containing Dakin’s solution were stored next to each other on a counter in a patient’s room. Instead of using the sterile water to dilute crushed medications for administration to the patient, the Dakin’s solution was used. Fortunately, the mistake was identified prior to administration.10
  • In an OR, it was discovered that housekeeping personnel obtained sterile sodium chloride irrigation solution bottles, added a disinfectant concentrate to the containers, and placed a label provided by the manufacturer over the irrigation solution label. This practice was discovered before any patients were affected.7 
  • Antibiotic solutions have inadvertently been reconstituted with 10% formalin solution and administered, resulting in patient hospitalization.7 Non-pharmacists working in pharmacy used empty gallon containers of distilled water to prepare the formalin solution. The formalin containers were accidentally placed with distilled water containers. 
  • Almost 4,000 patients were exposed to surgical instruments that were inadvertently washed with used elevator hydraulic fluid instead of detergent. The used hydraulic fluid was placed in empty detergent barrels. These barrels were mistakenly shipped to two hospitals that used the product as a detergent, as the barrel labels indicated.11

The common theme in these examples is that containers of one liquid were re-used to hold another, dramatically different, liquid. Applying a new label to the container that accurately indicates the new product may not be sufficient to solve this problem. The original label may be inadvertently left on the container, as well. Furthermore, the relabeling step could be forgotten, or the new label might not be placed over the original label but on the opposite side of the container.7 The shape, color, or location of the container may lead a person to assume that the container holds the original product/liquid, overlooking a clear label to the contrary—an example of confirmation bias.

Risk Reduction Strategies

The following risk reduction strategies may be appropriately applied to any clear solution that is used in healthcare.

Assessment

  • When conducting the admission assessment and subsequent assessments, evaluating the patient’s mental status and ability to understand the use of products left at the bedside.
  • If any assessment so indicates, removing patient treatment products from the patient’s bedside/room.
  • Routine assessment7 by a multidisciplinary team of facility departments to identify practices that increase the risk of inadvertent administration of non-drug/healthcare substances.

Education

  • Heightening awareness of both clinical and non-clinical staff concerning this issue (food services, housekeeping, central supply, laundry, etc) and explaining the dangers of adding non-drug items into drug, irrigation, or IV containers.
  • Educating patients/family about the purpose of solutions left at bedside.

Storage

  • Not leaving the solution at bedside.
  • Segregating patient treatment products from products used by patients for cleanliness/hygiene purposes.
  • Designating separate spaces for patient treatment products and items intended for ingestion (e.g., not placing patient treatment products on the overbed table, where water and food trays are placed).
  • Considering storing unused solutions in a central storage area, away from the patient room.
  • Installing shelves in patient rooms dedicated solely to patient treatment products.

Labeling

  • Standardizing labels for each solution that are unique in size, lettering, color and that are different from other labels, such as for sterile water.
  • Preparing unique labeling to clearly differentiate between irrigation/wound care products from those that might be used orally or parenterally.    

Containers

  • Providing a visual cue by standardizing containers for different types of solutions that are a different shape/color/size.10
  • Poking holes into empty plastic containers to prevent reuse.7

Preparation

  • Having the Pharmacy Department mix standard, extemporaneously prepared solutions used for healthcare,10 rather than mixing such solutions on the patient care unit.

Discarding       

  • Discarding unused solutions immediately after a treatment is provided.
  • Discarding any unlabeled containers or containers with more than one label.

Policies/Procedures

  • Developing written protocols that support the above risk reduction strategies and prohibit container reuse for other solutions.7 

Lesson Learned

In response to occurrences of incorrect use of Domeboro solution, one Pennsylvania facility developed a procedure for handling of Domeboro, which places the responsibility on Pharmacy for mixing and labeling all topical medicated solutions used for nursing care.

Elements of the policy include the following:

  1. When the order for Domeboro is entered in the pharmacy computer system, an alert appears to the pharmacist concerning how to enter the order for dispensing, specifying that Domeboro tablets are not sent to the nursing unit and that pharmacy prepares all Domeboro solutions for soaks or compresses.
  2. Pharmacy mixes a standard solution of 1:20 dilution by adding four effervescent tablets to 1000 cc of water for irrigation.
  3. Pharmacy labels the solution with:
    1. A computer-generated label from the pharmacy computer system
    2. For External Use Only
    3. Discard After: _________ [time specified]
    4. Any other warning labels considered appropriate
  4. Pharmacy enters the order for Domeboro solution with a route that ensures that it appears on the medication summary for nursing to verify, but it does not appear on the active worklist in the medication administration Kardex for charting.
  5. Nursing uses a function in the pharmacy computer system to reorder Domeboro solution from Pharmacy.

No reports of incorrect use of Domeboro solution have been reported by the facility to PA-PSRS since this process was implemented.

Notes

  1. Domeboro FAQ’s. [web site]. [cited 2005 Sep 2]. Morristown (NJ): Bayer Health Care LLC. Available from Internet: http://www.bayercare.com/htm/domefaq.htm.
  2. Domeboro astringent solution powder packets. [web site]. [cited 2005 Sep 2]. Morristown (NJ): Bayer Health Care LLC. Available from Internet: http://bayercare.com/htm/domepackets.htm.
  3. Bayer Health Care LLC. Material Safety Data Sheet. Domeboro ® powder packets [fact sheet]. Product code: 2324, 2322. 1997 Jul 31.
  4. Bishop NJ, Morley R, Day JP, et al. Aluminum neurotoxicity in preterm infants receiving intravenous-feeding solutions. N Engl J Med 1997;336:1557-61.
  5. Klein GL. Nutritional aspects of aluminum toxicity. Nutr Res Rev 1990;3:117-41.
  6. Aluminum. PDRhealth [online]. [cited 2005 Nov 7]. Available from Internet: http://www.pdrhealth.cm/drug_info/nmdrugprofiles/nutsupdrugs/alu_0020.shtml.
  7. Institute for Safe Medication Practices. Involving non-clinical departments in patient safety discussions can reduce risk of serious errors. Medication Safety Alert! 2002 Sep 4;7(18):1.
  8. Barnet B, Edwards MR. Toxicity, aluminum. Emedicine [online] 2002 Nov 26 [cited 2005 Nov 7]. Available from Internet: http://www.emedicine.com/med/topic113.htm.
  9. Domingo JL. The use of chelating agents in the treatment of aluminum overload. J toxicol Clin Toxicol 1989;27(6):355-67.
  10. Institute for Safe Medication Practices. Separate innies and outies. Medication Safety Alert! 2004;9(25):2-3.
  11. Thompson E. Duke health system under fire after hydraulic fluid used to clean instruments at two hospitals [press release online]. 2005 Jun 14 [cited 2005 Nov 4]. Available from Internet: http://abcnews.go.com/Health/wireStory?id=849639.
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