A 70-year-old woman rang the Poisons Information Centre with complaints of stinging and redness in one eye. She had instilled a drop of mometasone lotion instead of prednisolone with phenylephrine drops, prescribed after surgery for glaucoma. She was advised to flush the eye thoroughly with running water and to present to a doctor if symptoms persisted.
A person called about a colleague who had rinsed his eyes with chlorhexidine and cetrimide irrigation solution, instead of normal saline, from a first aid kit. The eye was stinging. He was advised to flush his eyes thoroughly for 15 minutes and to present to a doctor if symptoms persisted.
A general practitioner called regarding a man who presented following referral from the NSW Poisons Information Centre. The man was complaining of persistent redness and discharge after accidentally applying ear drops (acetic acid, isopropyl alcohol) into his eyes eight hours earlier. The general practitioner found corneal ulceration after fluorescein staining and referred the patient to an ophthalmologist.
Mistaken identity of similar looking products appears to be the most common cause of errors (Fig. 2). Safety tips to prevent accidental eye administration, particularly of ear drops, have been highlighted by the Institute for Safe Medication Practices.4 Suggestions include:
- keep the drops in the original box
- separate the drops – store different types of drops in separate locations
- discard leftover drops
- examine the product closely before administering
- warnings at the time of prescribing, dispensing or sale can help to remind consumers of the potential dangers of mixing up medicines.
Further research into the product packaging and labelling of topical pharmaceuticals is needed to help stop these preventable errors. Poisons centres can play an important role in pharmacovigilance and represent an underused resource of adverse event reports. Research could be conducted by obtaining follow-up information on exposures. It could help to identify a range of problems, such as confusing product packaging and labelling.
Acknowledgements: Thanks to Janet Gaon, Medicines Information Pharmacist, NPS MedicineWise, for assistance with the data coding of Poisons Information Centre calls and for reviewing the manuscript. Thanks also to Dr Naren Gunja, Medical Director, NSW Poisons Information Centre, for his helpful comments on this article.
Poisons Information Centre
Phone 131 126 from anywhere in Australia – 24 hours – for information and advice on the treatment of poisoning, bites and stings
- Hughes RG, Blegen MA. Medication administration safety. In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008. .
- Easton K, Morgan T. Medication safety in the community: a review of the literature. Sydney: National Prescribing Service; 2009. www.nps.org.au/__data/assets/pdf_file/0008/71675/09060902_Meds_safety_June_2009.pdf [cited 2013 Mar 6] .
- Brown JA. Accidental ocular administration of non-ocular pharmaceuticals. Abstracts of the 2012 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 25 May–1 June 2012, London, UK. Abstract No. 211. Clin Toxicol 2012;50:273-366. .
- Institute for Safe Medication Practices. Safe Medicine Newsletter. Ear drops in eyes: a painful mistake. www.med.navy.mil/sites/nhbeaufort/Patients/Documents/Safe%20Medicine.pdf [cited 2013 Mar 6] .