Accidental Chlorhexidine Injections

How many cases have occurred?


From a brief internet search we’ve been able to identify numerous other devastating cases of inadvertent chlorhexidine administration resulting in disabling injury and deaths. They’ve occurred because of pourable almost colourless versions of chlorhexidine (centre in image).


We’ve started compiling a list here – we have no doubt this represents only a fraction of the true number. We have no access to error report databases – if you’re aware of other cases then please let us know.

(For more information on this subject please click this link)

We can put a stop to this if the regulating authorities ban indistinct pourable chlorhexidine – see here for more details and sign the petition make them act.

December 2016 – 43 yr old female chlorhexidine accidentally injected into abdomen

Cerebral Angiogram – death

Intravenous chlorhexidine – death Japan

34 year old females – Epidural for Achilles’ tendon – tetraplegia, died 3 years later

5 babies fed chlorhexidine, 1 developed ARDS

Extensive chemical burns in newborn

Buccal Injection – mistaken for local anaesthetic during root canal treatment

Death of 6 year old in Florida US

43yr old abdominal rectus sheath injection 2016 NZ

Neonates fed chlorhexidine – mistaken for sterile water – lip burns, pulmonary oedema

Injected into arterial line – thumb necrosis

3rd degree burns in newborn

Leg angiogram – amputation

3 cases where applied to eye instead of balanced salt solution

Patient safety alert from National Pharmacy Association

Epidural Injection (UK) – paralysis

Epidural Injection (Australia) – paralysis

Epidural injection (Sweden) – intractable pain

Epidural near miss (Australia)

Cerebral angiogram and coiling – death

Ankle injection (Australia)

Pacemaker insertion – cardiac arrest

Renal Dialysis

Biliary tract injection – sclerosing cholangitis

Injection into the eye (intraocular)

200 ml oral ingestion – death in 80year old

Intravenous injection – ARDS

Accidental oral ingestion -death 70 year oldĀ 

2 (perhaps 3) cases of chondrolysis of knee

Bilateral corneal abrasions from chlorhexidine soaked eye shields

3 babies died, 13 major injuries from chlorhexidine

6 cases of accidental chlorhexidine knee infiltration during arthroscopy leading to permanent damage of cartilage

3 babies accidentally fed chlorhexidine (Finland)

Inadvertant injection of 0.5% chlorhexidine in 70% ethanol in newborn

National Pharmacy Association – Patient Safety Alert

Patient Safety Alert – NHS UK