AUTHOR BIOGRAPHY
Myungsun Ro, PharmD, MS, Patient Safety Authority
Myungsun (Sunny) Ro (mro@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority (PSA). Her responsibilities include analyzing and synthesizing data from various sources to identify opportunities to improve patient safety, as well as writing scientific articles for publication in the PSA’s peer-reviewed journal, Patient Safety.
Abstract
Multiple events involving patient harm from the use of undiluted glacial acetic acid have been reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Glacial acetic acid is anhydrous pure acetic acid available in concentrations between 99.5% and 100%.1–4 Unlike acetic acid solutions which have various medical uses when diluted to different concentrations (e.g., 0.25% for irrigation, 2% for otic use), glacial acetic acid is highly corrosive; has no medical purpose; and has been associated with serious patient harm, such as severe tissue damage and third-degree burns.1–4 Because glacial acetic acid is not considered to be a drug, it is not regulated by the U.S. Food and Drug Administration (FDA) to have standardized labeling on its containers to prominently display the strength of acetic acid and warnings against medical use.2,3 Despite our previous publication describing two cases involving unintended applications of glacial acetic acid and several strategies to prevent error,1 we have recently received PA-PSRS reports of additional patient injuries due to the use of glacial acetic acid. Therefore, we advise facilities to review and implement the Action Items listed below.
