Ban Indistinct Pourable Chlorhexidine

In 2010 a tragic event where chlorhexidine was mistaken for saline left Grace Wang paralysed (see here). A formal investigation of the incident made this recommendation:

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However indistinct preparations of chlorhexidine still exist in many hospitals leaving patients at unnecessary risk. Attempts to have it banned through current health care frameworks have been unsuccessful.

Numerous similar cases of inadvertent chlorhexidine injection have occurred (see here) leading to amputations, paralysis and deaths. All have occurred in the presence of pourable, almost colourless versions of chlorhexidine.

We need your support – please click here and sign the petition to ban indistinct pourable chlorhexidine – this goes straight to regulating authorities and manufacturers.

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Pink chlorhexidine (middle of image) is easily mistaken for colourless solutions. There’s no need for these indistinct solutions and safer versions (e.g. red chlorhexidine – right of image) are already in use in many hospitals without problem and at no extra cost.

Watch ‘Gina’s Story’ to see how arterial injection resulted in leg amputation at the waist.

Read ‘Mary McLinton’s Story’ – she had chlorhexidine injected into the blood supply to her brain. She died two weeks later in agony, at one point begging a nurse to kill her.

No one took action to change the process before this tragedy occurred.”

We’re trying but need your help. Please sign the petition here.

Frequently Asked Questions:

How many cases have occurred?

Why haven’t the numerous chlorhexidine injection cases been identified before?

What are the opinions of front line staff?

Why don’t we just stop ordering pourable pink chlorhexidine into hospitals?

Have the manufacturers been made aware of the issue?

Why doesn’t everyone label gallipots?

Why not just use Iodine?

What about using chlorhexidine applicators?

Which chlorhexidine preparation should we use?

Why can’t staff ‘just be more careful’?

What were the recommendations in response to the St George Hospital epidural tragedy?

Why haven’t regulating authorites already banned it?

Unfortunately the only thing stopping us banning indistinct pourable chlorhexidine is us and the deficient health care safety systems we’ve created.

Let’s change this – please sign the petition to ban indistinct pourable chlorhexidine.

13 thoughts on “Ban Indistinct Pourable Chlorhexidine

  1. There are 1 and 2% Chlorhexidine swab and swap stick applicators in use in many Australian hospitals. Unfortunately the darker pink can make insertion sites look cellulitic and cause early removal as a result. We went back to a clear swab stick for that reason. There are green tinted ones too which some procedural areas don’t like with drapes. 0.5% is less commonly used these days with CVC bundle to reduce CLABSI and for IV related SAB infections.

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    1. Hi, Thank you so much for the comment. Perrigo / Orion have listened to the voices of front line staff – they’ve created a distinctly coloured chlorhexidine solution which does not stain the skin & so overcomes the issue you mentioned of cellulitis.
      Unfortunately they are only supplying this as a 2% solution. They are due to release a 0.5% solution over the next month.
      Despite 2% chlorhexidine appearing in several policy guidelines there is no evidence to support its use over 0.5%. That 2% appears in many guidelines is a result of corruption driven by chloraprep – you can read more about it in this link.
      https://patientsafe.wordpress.com/which-chlorhexidine-preparations-are-suitable-to-use/

      There are numerous guidelines indicating 0.5% being used for neuraxial blocks.
      It would be ideal if on the front line this was as simple as possible – a 0.5% chlorhexidine solution which is distinct (and may or may not stain the skin – there are benefits to seeing where it’s placed) and is presented in applicators for those who need it.

      While we wait for this there is absolutely no reason to have indistincy pourable versions of chlorhexidine in our hospitals.
      We have no financial interest with any of these products. Thank you again for your comment

      Like

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