AI Article Synopsis

  • This case report underlines the risk of errors in removing foreign bodies from the eye within a busy Accident and Emergency (A&E) setting.
  • A serious incident occurred when a silver nitrate stick was mistakenly used instead of a cotton bud, leading to a corneal injury that required further medical treatment.
  • To enhance patient safety, the report recommends better organization of consumables, including separate storage and proper packaging, to reduce the chance of similar mistakes occurring in the future.

Article Abstract

Purpose: This case report highlights the potential for error when removing corneal foreign bodies in a shared speciality area in Accident and Emergency (A&E).

Observations: This case presents the accidental use of a silver nitrate stick rather than a cotton bud to remove a corneal foreign body. This resulted in a corneal injury requiring ophthalmological referral and management with topical antibiotics, topical steroids and lubricants.

Conclusions: Mistaking a silver nitrate stick for a cotton bud is a tangible risk in a busy A&E and can result in significant corneal injury. Clinicians and departments can greatly reduce this risk by having separate and secure storage of similar consumables, as well as keeping consumables in original packaging and discarding of the remainder after a pack has been opened. Minimizing the risk for error will better safeguard and improve patient safety.

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Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900634PMC
http://dx.doi.org/10.1016/j.ajoc.2021.101016DOI Listing

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