Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident related to a surgical procedure to the eye which resulted in patient harm from 100% alcohol being applied to the cornea without the solution being diluted to the desired lower strength.

Patients undergoing collagen cross-linking procedures to the eye, require removal of a section of corneal epithelium by applying 18% or 20% alcohol to the cornea. When unable to procure a pre-diluted solution, practice was to dilute 100% alcohol to achieve the desired strength. In the reported cases the dilution process was inadvertently omitted, resulting in 100% alcohol being applied to the cornea, causing damage to the ocular surface. 

We worked with The Royal College of Ophthalmologists (RCOphth) Quality and Safety Committee who used our findings to publish a Safety Alert. The Safety Alert asked members to evaluate the use of alcohol during corneal cross-linking surgery and whether suitable 18% or 20% alcohol preparations could be sourced from a specials manufacturer.

The recommendations made by RCOphth were communicated to the Medicines Safety Officers network across NHS providers.

Publication reference: PRN01208