Chemical burn to a neonate from use of chlorhexidine

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, the National Patient Safety Team identified a patient safety issue around the use of chlorhexidine in neonatal care causing chemical burns.

Chlorhexidine is widely used as a topical antiseptic and disinfectant agent for skin cleansing.  In neonatal care, it is often used to clean a baby’s skin and umbilical cord prior to an interventional procedure.  However, if too much chlorhexidine is applied, potentially due to not using an applicator, or using the wrong size of applicator, then this can result in the excess chlorhexidine pooling under the baby.

Skin reactions to chlorhexidine applied to neonatal skin are widely reported in the literature, ranging in severity from erythema/severe redness to chemical burn, excoriation, and skin breakdown.  The incident reported to the NRLS identified an infant sustaining a chemical burn when a 10ml applicator was used instead of a 3 ml applicator, similar incidents were found in the NRLS.

We shared our findings with the Neonatal and Paediatric Pharmacists Group who have produced a position statement, endorsed by the British Association of Perinatal Medicine, to help provide clarity in the use of chlorhexidine in neonates.

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.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. 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.