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

We’ve identified a disturbingly large number of cases of accidental chlorhexidine administration from the internet – see here. Why haven’t they been identified before?

Healthcare incident reporting systems are profoundly limited.

The lessons learned from the near miss epidural event at one Sydney Hospital had (and still has) no way of being effectively communicated to prevent the catastrophic event, down the road, at St George Hospital 3 weeks later.

The nature of adverse events is that they are dispersed in time and place.

Without actively seeking out adverse events our reporting systems do not link together so at best we only recognise clusters of events that occur in one state.

Our reporting systems are designed for reporting adverse events and near misses. They are cumbersome, take significant time to complete by already time poor staff. The incident reports are reviewed by staff who often don’t work in, or have limited appreciation of, the complexity of front line work environments. Front line staff rarely, if ever, feel anything effective is done in response to their reports, so understandably become reluctant to complete them.

Unfortunately the TGA, who have the capacity to ban indistinct pourable chlorhexidine, have a completely separate cumbersome reporting system the vast majority of staff are unaware of. They don’t receive the incident reports that staff may have filled in.

When pourable chlorhexidine was first introduced it’s colour was very distinct. One of our members remembers, when first seeing tinted pink chlorhexidine, saying to a midwife ‘this is really dangerous, it’s going to end up in someone’s spine’. This was 3 years before the event at St George.

Still, today, front line staff do not have the ability to remove this hazard.

We need a hazard feedback system where identified hazards are reported and effective solutions transparently implemented.

In the interim, please help by signing this petition (click here) which goes straight to regulating authorities and manufacturers, to ban almost colourless pourable chlorhexidine.