Case study: Surgical skin preparation solution entering the eye during surgery

Through its review of recorded patient safety events the National Patient Safety Team identified a risk of harm from accidental administration of surgical skin preparation solutions accidentally entering the eye.

A review of similar incidents identified issues associated with staff awareness of the differences between alcoholic and aqueous formulations, mis-selection of alcohol-based solution instead of aqueous-based solutions, and poor application technique.

Collaboration between the Association of Perioperative Practice (AfPP), Becton Dickinson (as industry partners) and NHS England led to the development of the Surgical Skin Preparation Decision Tool.

This interactive tool supports practitioners to select the most appropriate surgical skin preparation as advised by NICE guidance (NG125), which recommends surgical skin preparation solutions based on efficacy of antiseptic properties and the options recommended against certain constraints.

The tool is also an educational resource to aid competency achievement and reduce the risk from surgical skin preparation solutions used around the eye.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.