Why haven’t the regulating bodies already banned indistinct chlorhexidine?

Front line staff are concerned tinted pink and other almost colourless pourable solutions of chlorhexidine are still used at many hospitals. There is no benefit for this obvious hazard to persist in the workplace, however current frameworks for healthcare safety appear unable to remove it.

We have tried, through correspondence with the Therapeutic and Goods Administration (TGA) to have it banned from hospitals. Their response is disappointing. Please note since their replies, we have discovered numerous other reports of inadvertent chlorhexidine injection from throughout the world.

The TGA has a seperate reporting system called IRIS that front line staff haven’t heard of. Unfortunately the TGA base much of their decision not to ban indistinct chlorhexidine on a lack of reports into this reporting system (see here).

The line: ‘the issue relates to clinical practice rather than a fault with the device itself’, leaves us concerned the TGA may not grasp the importance of human factors in system safety.


Further correspondence 9/6/16:


The TGAs claims of few reports perhaps highlights how cumbersome current reporting systems are. They may be insufficiently staffed to look for other case reports of inadvertent chlorhexidine injection – as we discover them we are adding them to this list  and forwarding them to the TGA and other relevant bodies. If you are aware of any not included in this list then please let us know.


The TGA is the only body with the capacity to ban this obvious hazard from our hospitals. Please provide your encouragement by signing this petition – click here.