Healthcare organizations need to take immediate actions to encertain that only diluted acetic acid solutions are supplied in patient treatment. Eliminate the use and also purchase of glacial acetic acid.

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The Institute for Safe Medication Practices (slrfc.org), which operates the National Medication Errors Reporting Program, is warning healthcare providers around repetitive cases of accidental application of “glacial” acetic acid (≥ 99.5%) to skin or mucous membranes instead of an extra diluted form. Glacial acetic acid is the most concentrated form of acetic acid available. Inadvertent application of this corrosive chemical has actually caused significant burns, scarring, and various other irreversible damages to skin or mucousmembranes. The complying with are among the cases reported to slrfc.org:

A patient continual serious burns and long-term scarring after glacial acetic acid (≥ 99.5%) was applied to her skin instead of a 5% acetic acid solution during a surgical procedure. The pharmacist was initially uncertain around dispensing the solution provided that the label declared “Acetic Acid USP (Glacial),” but he later on dispensed it without better dilution.

A nurse dubbed the pharmacy for “acetic acid for irrigation” for a young womale through paraplegia, osteomyelitis, and also bilateral better trochanter wounds. An knowledgeable pharmacist, yet new to the school, inserted glacial acetic acid at the home window for pickup. This was offered for 2 days rather of a diluted develop. The undiluted solution resulted in burns to the extent that the wounds would not heal, necessitating disarticulation at the hips.

A physician in an ambulatory surgical center requested 4% acetic acid for use during anoscopy (comparable to acetic acid use throughout a cervical colposcopy). Unit staff inadvertently purchased a bottle of glacial acetic acid directly from a clinical supplier instead of the 4% solution. Although labeled “glacial acetic acid,” the solution was not further diluted. The patient experienced serious anal burns.

A nurse received glacial acetic acid from a pharmacy technician and poured the undiluted solution into a bowl on the sterile field in the operating room (OR).The surgeon was utilizing acetic acid to determine rectal condyloma. He soaked a gauze pad and inserted it in the patient’s rectum. The patient compelled comprehensive treatment and prolonged hospitalization due to tworry damage caused by the undiluted solution.

Diluted forms of acetic acid are offered to treat specific infections of the external ear and ear canal (2% solution),or to determine cervical dysplasia during colposcopy or dysplasia of various other mucous membranes (3-5%solution; e.g., table vinegar is regularly used). A 0.25% sterile solution is commercially easily accessible and also used forits antimicrobial properties as a premixed watering, generally for bladder installation or wounds.

A widespread element in each case has been staff unfamiliarity through the term “glacial,” which refers to thereality that, at its freezing suggest, pure acetic acid creates crystals that look choose a glacier. Unfamiliarity with“glacial” has led staff to order the wrong product from a supplier or usage the product without knowledgethat better dilution is forced.

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Figure 1. Label on glacial acetic acid bottle, front (L) and back label panels (R)

Glacial acetic acid is a chemical, which means it is not regulated by the US Food and Drug Administration(FDA). Hence, label warnings are not standardized. While some containers have no warnings at all (Figure 1), various other container labels bring a skull and crossbones via warnings about the product’s corrosiveness onthe side or ago panel. Although the stamina of the solution is mainly detailed on the label, it is basic to miss out on or can be misunderstood. For example, via the product in Figure 1, “99.5%” is hidden on the earlier panel andhas actually not been taken as the concentration bereason it is preceded by the word “assay.”

Take these steps to prevent this painful and also harmful event:

Remove from stock. Rerelocate glacial acetic acid from the pharmacy, discard it safely, and also replace it withvinegar (5% solution) or commercially obtainable diluted acetic acid 0.25% (for irrigation) or 2% (for oticuse). Limit availcapacity to these concentrations just. Encertain that the acid is not stored in clinical areassuch as the OR, clinics, doctor practice sites, ambulatory surgical centers, and also other procedurallocations. Glacial acetic acid has actually no use in its existing develop in clinical medicine.

Restrict purchasing. Rely on pharmacy to purchase acetic acid services for all procedural areas.

Restrict selections once purchasing. If using purchasing software application, investigate the opportunity of restrictingaccessibility to glacial acetic acid by developing apconfirmed “favorites” listings and/or making it invisible to purchasersso it is not schosen by mistake.

Encertain correct strength is ordered. Verify that the correct strength hasbeen requested from the vendorand also got in the pharmacy.

Educate staff. Encertain that all clinical, pharmacy, nursing, and technical staff who prescribe,dispense, usage, or purchase commodities are aware of the distinctions between glacial acetic acid anddiluted forms of acetic acid.

Order 5% as “vinegar.” Physicians who perform colposcopy or anoscopy with 4% or 5% acetic acid deserve to order it as “vinegar,” which may be offered for this function. Ordering “vinegar” reduces the potential for confusion via glacial acetic acid. If vinegar will certainly not suffice, it may be feasible to purchase pre-diluted creates of acetic acid, which need to then be diluted by pharmacy to the needed concentration and also labeled.

Verify product. Require an independent double-check of acetic acid solutions prior to dispensing or using the product.

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As detailed, product label shortcomings have actually contributed to the damage reported through glacial acetic acid. Current warnings may be entirely lacking, or inconsistent and also inconspicuous. slrfc.org has actually contacted chemistry organizations to talk about these contributing components in the hope that improved warning devices deserve to be developed by the chemical industry.