Original communication| Volume 24, ISSUE 2, P421-425, August 1948

The prevention of chemical sloughs Identification of procaine, alcohol, ether, boric acid, and other colorless solutions commonly used in the operating room

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      Despite its simplicity, accidents resulting from the administration of local anesthetic agents and parenteral fluids have undoubtedly been more numerous than one would be led to believe from the few isolated cases which have been reported. While this may be construed as indicative of the infrequency of such accidents, nevertheless, it is more likely due to a failure to publish them. Physicians are always eager to report successes, but are equally reluctant to record failure or mistakes.
      We believe that more accidents and reactions occur as the result of injection of the wrong solution, or one improperly prepared, than those due to sensitivity to the agent. When a physician has had the misfortoune of administering the wrong solution, and a severe reaction has ensued, he is of the opinion, and perhaps righly so, that he would be blamd for the accident, and so it has seemed to him that no good purpose would be served by reporting it. Thereby, the custom has grown up of not recording these accidents, although a service might have been rendered by repeatedly calling to the attention of the medical profession the possibility of mistakes, and emphasizing the need for safeguards in an effort to prevent them. It was with this idea in mind that the present study was undertaken, since we were unable to find reference in the medical literature to any work on this problem. Discussion may stimulate further investigation which may lead to better prophylaxis.
      The migration of student and graduate nurses through the various operating rooms has enhanced the possibility of the surgeon's being given a syringe containing the wrong colorless solution. Substitution accidents may occur in several ways. The error may have been made in the pharmacy where either the wrong or an improper solution was made, or the final package was improperly or incompletely, labeled and identified. Of more frequent occurrence, in our opinion, is the error made by the nurse, the house officer, or the surgeon himself, who having several colorless solutions, such as alcohol, ether, procaine, saline, etc., on the instrument tray, may draw into the syringe the wrong solution for injection. While this error may seldom occur, when it does the result may be a
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