DISCUSSION
Over the years, I have seen variations of this case: hemoccult solution placed in the eye under the impression it was a topical anesthetic, and 1:1000 epinephrine given intravenously (IV) when it was thought to be 1:10,000 concentration.
The way to avoid this mistake is to force yourself to take a good look at whatever medication you are administering to a patient, be it by mouth or IV, on the eye or skin, in a muscle, or up the rectum. Read the name of the medication before giving it. It is fortunate for all involved in this case that no serious or permanent injury occurred.
According to the manufacturer of CaviCide (Metrex), it is a “convenient, ready-to-use, intermediate-level surface disinfectant which is effective against tuberculosis, HBV, HCV, viruses (hydrophilic and lipophilic), bacteria (including MRSA and VRE), and fungi. It is safe for use on non-porous surfaces, and for cleaning environmental and medical device surfaces.” While it sounds great for cleaning surfaces and objects, it is clearly not the right product to spray on a wound.
This accident falls under the general heading of a medication error. This category includes: selecting the wrong medication or dosage; giving the medication at the wrong frequency; administration to the wrong patient or via the wrong route; or failure to monitor the patients’ response to the medication. In the risk management world, it is recommended that providers consistently perform the “five rights” of medication administration: right patient; right drug; right dosage; right time; and right route. This case illustrates the problem of “right drug.” Clearly, CaviCide was not the right drug for this patient. Given different circumstances, the harm could have been significant.
SUMMARY
Fortunately, this is a relatively simple take-home message: know what drug you are giving your patient, always.