The NPSA has issued a ‘Signal’ relating to confusion between different strengths and preparations of phenol, resulting in severe harm to a child when a high-strength product is injected in error.

 
The antibacterial phenol is available in different formulations, the most common include: 80% aqueous (liquefied) phenol used topically in podiatry for removal of ingrown toenails; 5% oily phenol injection, used in treatment of haemorrhoids, and other low strength forms used for pain relief and to control spasticity. Confusion between these products has resulted in patient harm.

The National Reporting and Learning Service (NRLS) was alerted to the problem following the case of a child who suffered severe harm following confusion between different forms of phenol at one trust.  Six further incidents on the database were then located and further learning obtained through local investigations at the two trusts where patients had been harmed.  The alert discusses briefly the local action taken and asks ‘Could this happen at your organisation? Is there scope for confusion in different forms of phenol stocked in theatre (and could alternative products be used for haemorrhoids)?’