ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook
Site Search by PicoSearch. Help

WorthRepeating...
Ethyl chloride ignites


From the August 26, 2004 issue


Sadly, we must report another surgical fire associated with ethyl chloride spray. We last wrote about this in the March issue of the newsletter (WorthRepeating... Extreme caution needed with flammable products, ISMP Medication Safety Alert! March 11, 2004). In this latest case, a physician applied ethyl chloride spray to an area on a girl’s forehead and waited for it to dry. He then turned on the cautery device as he proceeded to drain an abscess. Due to hair loss, the teenager was wearing a flammable synthetic wig, which soon ignited after the heat source was applied to her forehead. The flames were quickly extinguished
but the patient sustained first degree burns to her ear.

As we stated in our March publication, ethyl chloride containers may have poorly visible warnings about flammability. The reporter pointed out that one could clearly read “topical anesthetic skin refrigerant - relieves pain” but easily miss statements about it being flammable because they are set in a small type size. There is an icon on the bottle to indicate that it is flammable, but it looks more like a flower than a flame. Please don’t let this happen again. Take time now to ensure that someone at your location notifies physicians, nurse practitioners, and all other healthcare workers about the dangers of ethyl chloride spray and the potential for burns when these products are used in conjunction with a heat source. Even static discharge may ignite it! Reevaluate the need for flammable products in your facility, as there are often safer alternatives, especially for topical anesthetics. At the least, add an auxiliary label to warn about flammability before these products are dispensed to units.

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Survey Results
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officer Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP