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Authors

  1. Cohen, Michael R. SCD, MS, RPH

Article Content

ACRONYMS

Swiftly banish "SWFI" from clinical use

Many clinicians use the acronym SWFI for sterile water for injection. But use of even common acronyms and abbreviations such as this can lead to misunderstandings. ISMP received a report about a practitioner who misunderstood the acronym SWFI to mean sterile water for irrigation, which the practitioner then used to reconstitute a vial of ampicillin. The reconstituted solution was then further diluted in a minibag of saline and administered to a patient by I.V. infusion. The patient wasn't harmed. The two products aren't interchangeable, but the only difference between sterile water for injection and sterile water for irrigation is that USP allows sterile water for irrigation to have a larger particulate matter count.

 

In another case, a different practitioner thought SWFI meant salt water for injection and used 0.9% sodium chloride injection to reconstitute a drug that required sterile water, a potentially more serious mistake.

 

Don't assume that everyone understands the acronym SWFI, and avoid using it.

 

PHENOL MISUSE

Feel the burn

Recurrent painful ingrown toenails (onychocryptosis) occur when a spicule of the lateral nail plate pierces the lateral nail fold and penetrates the skin.1 The condition can be treated surgically by excising a section of the nail or an entire nail plate after matricectomy (the process of destroying all or part of the nail matrix). During chemical matricectomy, local anesthetic is injected into the base or proximal aspect of the toe before the nail matrix is destroyed chemically using phenol, also known as carbolic acid.

 

A recent report of an injury caused by phenol involved a 17-year-old patient who was undergoing this procedure. Afterward, a nurse used an unlabeled bowl of clear fluid to cleanse the patient's foot. When the patient experienced a burning sensation, the nurse realized that the bowl contained phenol, not the expected normal saline solution. Although the patient received first aid and a poison control center was contacted, the condition worsened and required additional care at a tertiary healthcare facility with a burn center (see photos below).

 

Phenol is a hazardous chemical associated with chemical burns when mishandled. Never decant phenol (or any liquid) into an unlabeled container used concurrently during surgery or any other procedure. This has often contributed to serious mix-ups between fluids used during surgery and has caused medication error-related tissue injury and death. In one reported incident, phenol was injected into the toe instead of the local anesthetic. The extent of the injury is unknown.

  
Figure. Area of phen... - Click to enlarge in new windowFigure. Area of phenol burn after 1 day.
 
Figure. Area of phen... - Click to enlarge in new windowFigure. Area of phenol burn after 9 days.

Unfortunately, the hazards of phenol often aren't recognized, and processes may not be in place to address safe use. Pharmacists should determine if phenol is stored and/or used at their facility and remove unnecessary phenol to prevent problems. Facilities using phenol for procedures should consider ordering prepackaged phenol applicators, which are much safer than bottles of liquid phenol and reduce staff exposure to phenol. Phenol applicators contain only a small amount of phenol in an ampule-like container for use during chemical matricectomy (see photos below).

 

In addition, clinicians working with phenol must be prepared to provide immediate treatment should the substance be mishandled. Polyethylene glycol 300 (PEG300) solution should be kept with phenol for decontamination of skin inadvertently exposed to phenol.

  
Figure. This package... - Click to enlarge in new windowFigure. This package contains a single phenol applicator holding just 0.175 to 0.2 mL.
 
Figure. Phenol appli... - Click to enlarge in new windowFigure. Phenol applicator removed from the packaging.

REFERENCE

 

1. Goldstein BG, Goldstein AO. Management of ingrown toenails. UpToDate. 2017. http://www.uptodate.com. [Context Link]